HUD-40072 Claim for Rental of Purchase Assistance

U.S. Department of Housing
and Urban Development
Office of Community Planning
and Development

Claim for Rental or Purchase Assistance
Under Section 104(d) of Housing and Community
Development Act of 1974, as amended
For Agency
Use Only

Name of Agency

OMB Approval No. 2506-0016
(exp.07/31/2008)

Project Name or Number

Case Number

Public reporting burden for this collection of information is estimated to average 1.0 hour. This includes the time for collecting, reviewing, and reporting the data.
The information is being collected under the authority of Section 104(d) of the Housing and Community Development Act of 1974, as amended, and implementing
regulations at 24 CFR Part 42 and will be used for determining whether you are eligible to receive a payment to help you rent or buy a new home and the amount
of any payment. Response to this request for information is required in order to receive the benefits to be derived. This agency may not collect this information,
and you are not required to complete this form unless it displays a currently valid OMB control number.
Privacy Act Notice: This information is needed to determine whether you are eligible to receive a payment to help you rent or buy a new home. The Agency will help
you complete this form. If the full amount of your claim is not approved, the Agency will provide you with a written explanation of the reason. If you are not satisfied
with the Agency’s determination, you may appeal that determination. The Agency will explain how to make an appeal. You are not required by law to furnish this information,
but if you do not provide it, you may not receive any payment for these expenses or it may take longer to pay you. This information is being collected under the authority
of Section 104(d) of the Housing and Community Development Act of 1974, as amended. The information may be made available to a Federal agency for review.
1. Your Name(s) (You are the Claimant(s))

1a. Your Present Mailing Address(es)

2a. Have all members of the household moved to the same dwelling?

Yes

No (If "No", list names of all members and the address to which they moved in the Remarks

Section) 2b. Do you (or will you) receive a Federal, State, or local housing program subsidy at the unit you moved to?

Dwelling

1b. Your Telephone Number(s)

When Did You
Rent/Buy This Unit?

Address

Yes

No

When Did You Move
To This Unit?

When Did You Move
Out of This Unit?

3. Unit That You
Moved From
4. Unit That You
Moved To
5. Computation of Payment : Complete Items 13 and 14 on the back of this form before completing this section.
If you are filing for purchase assistance, check this box
and skip line (1).
Item
To Be Completed By Claimant
(1) Monthly Rent and Estimated Average Monthly Utility Costs for Unit
That You Moved To (from Item 13, line (8), column (a))

For Agency Use Only

$

$

$

$

$

$

(2) Monthly Rent and Estimated Average Monthly Utility Costs for Comparable
Replacement Dwelling (from Item 13, line (8), column (c)) (to be provided by Agency)
(3) Lesser of line (1) or (2) (If claim is for purchase assistance enter amount from line
(2))
(4) Total Tenant Payment (from Item 14, line (8) or as computed by PHA)
(5) Monthly Need (Subtract line (4) from line (3))
(6) Amount of Payment (Renters multiply amount on line (5) by 60;
Agency will determine purchase assistance amount)
(7) Cost of Security Deposit
(8) Cost of Credit Check
(9) Amount of Claim (Add lines (6), (7) and (8))
(10) Amount Previously Received, if any
(11) Amount Requested (Subtract line (10) from line (9))

6. Certification: I certify that this claim and supporting information are true and complete and that I have not been paid for these expenses from any other
source.
Signature(s) of Claimant(s) & Date

X
Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)
To be Completed
by the Agency

7. Effective date of eligibility
for relocation assistance

10. Payment To Be Made In:

8. Date of referral to comparable

Lump Sum

replacement dwelling

Monthly Installments

(only for down payment assistance)
Payment Action

Amount of Payment

11. Recommended

$

12. Approved

$

Previous editions are obsolete

9. Date replacement dwelling inspected
and found decent, safe and sanitary
Other Installments
(specify in the Remarks Section)

Signature

Page 1 of 2

Name (Type or Print)

Date

form HUD-40072 (04/2005)

13. Determination of Rent and Average Monthly Utility Costs
Instructions: To compute the payment, entries on line (8) must reflect all utility services. Therefore, identify on lines (2) through (5) each utility necessary to
provide heat, hot water, cooking, lighting, and water and sewer. In those cases where the utility service is not covered by the monthly rent, indicate the estimated
out-of-pocket monthly cost. In those cases where the utility service is covered by the monthly rent, enter "IMR" (In Monthly Rent). Determine the estimated
average monthly cost of a utility service by dividing the reasonable estimated yearly cost by 12. If you receive (or will receive) a monthly housing subsidy at
the replacement dwelling (e.g., Section 8 Housing Assistance Payment
(HAP)), enter the applicable amount on line (7), column (a).
Average Monthly Cost

Item
(1)

Rent (The amount paid under the terms and conditions of
occupancy. It may or may not cover any utilities.)

Unit That You Moved To
(Do not complete if claim is for purchase assistance)
(a)
(b)
Claimant
For Agency Use Only

Comparable
Replacement Dwelling
(c)
To Be Provided By Agency

$

$

$

$

$

$

$

$

$

(2)
(3)
(4)
(5)
(6)

Gross monthly rent and utility costs (add lines (1) through (5))

(7)

Monthly housing subsidy, if applicable (e.g., Section 8 HAP)

(8)

Net monthly rent and utility costs (subtract line (7) from line (6))

14.Determination of Total Tenant Payment (See 24 CFR 5.628)

If PHA computes Total Tenant Payment, this section need not be completed.
Household Income
(a)
To Be Completed By Claimant

Item
(1) Annual Gross Income
of Household. Include
income from net family
assets. Enter name of
each household member with income. (See
24 CFR 5.609)

(b)
For Agency Use Only

$

$

$

$

(2) Total gross annual income (add entries in line (1))
(3) Adjustments to income (see 24 CFR 5.611)
(a) Dependent deduction ($480 X number of dependents)
(b) Elderly household deduction (Enter $400, if head of household or
spouse is 62 years or older or handicapped or disabled)
(c) Allowable child care expenses (expenses for children 12 and under
that enable a family member to work or further education)
(d) Allowable handicapped assistance expenses for nonelderly family
(that enable handicapped or disabled person to work or another
household member to work)
(e) Allowable handicapped assistance expenses and medical expenses
for elderly family (if head of household or spouse is 62 years or older
or handicapped or disabled)
(f) Total adjustments to income (Add lines (3)(a) through (3)(e))
(4) Subtract line (3)(f) from line (2) (This is annual adjusted income)
(5) Divide line (4) by 12 (This is monthly adjusted income)
(6) 30 % of line (5)
(7) 10 % of gross monthly income (Divide line (2) by 120)
[1]

(8) Greater of line (6) or (7) (Enter in Item 5, line (4))
Remarks:

[1] If the claimant receives public welfare assistance in a State or community that designates a specific portion of such assistance as a shelter allowance
and adjusts that amount according to actual housing costs, enter the designated amount in Item 5, line (4), if it is greater than the amount in Item 14, line
(8).

Previous editions are obsolete

Page 2 of 2

form HUD-40072 (04/2005)