HUD-50164 Unexploded Ordinance

OMB Control #: 2577-0169 Exp. Date: xx/xx/202x

Unexploded Ordnance Hazards Disclosure – Waikoloa Maneuver Area (WMA)

OMB Burden Statement: The public reporting burden for this information collection is estimated to be 0.3 hours, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Assurances of confidentiality are not provided under this collection. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions to reduce this burden, to the Office of Public and Indian Housing, US. Department of Housing and Urban Development, Washington, DC 20410. HUD may not conduct and sponsor, and a person is not required to respond to, a collection of information unless the collection displays a valid control number.

Privacy Notice: The Department of Housing and Urban Development (HUD) is authorized to collect the information on this form by 24 CFR 50.3(i) and 24 CFR 58.5(i)(2). The purpose of this form is for the lessor to disclose whether unexploded ordnance hazards are present. The Personally Identifiable Information (PII) data collected on this form are not stored or retrieved within a system of record.

Over the past two centuries, the Department of Defense (DOD) has used land throughout the country as military training and weapons testing grounds. As training and testing needs changed, DOD obtained property or returned it to private or public uses. Today, the U.S Army Corps of Engineers (USACE) has primary responsibility for cleanup of these Formerly Used Defense Sites (FUDS). In many locations, live ammunition was used and the removal of superficial and subsurface unexploded ordnance and munitions and explosives of concern (UXO/MEC) is incomplete. Together with the USACE, local city, county, and state government agencies have the primary responsibility to ensure adequate regulatory controls exist to protect human health and safety.

Living in a FUDS area can pose serious health hazards if not managed properly. HUD’s concern for resident safety at UXO/MEC sites is paramount. If a lessee believes his or her civil rights have been violated, including in relation to environmental conditions, contact the San Francisco Office of Fair Housing and Equal Opportunity (FHEO) ([email protected], 415-489-6524, 800-347-3739, 415-436-6594 (TTY)). In the case of the Waikoloa Maneuver Area FUDS, until remediation is complete, and the local regulatory agency issues the appropriate site closure document(s), the head of households/lessees of all Public Housing and Housing Choice Voucher programs must complete this acknowledgement form annually.

Agency:
Participant:
Project:
Unit Address:

LESSOR’S DISCLOSURE

1. Presence of unexploded ordnance hazards exist (check one below):
    Known unexploded ordnance hazards are present. Details are:

   
   

   
   

2. Records and reports available to the Lessor (check one below):

 Lessor has provided Lessee with all available records, informational materials and reports pertaining to

unexploded ordnance hazards (list documents below).

Head of Household’s/Lessee’s Acknowledgment (Initial)

Head of Household/Lessee has received copies of all information listed above.

ACKNOWLEDGEMENT AND ACCEPTANCE

The following parties have reviewed the information on the previous page and certify, to the best of their knowledge, that the information they have provided is true and accurate.

I/We, the undersigned, certify under penalty of perjury that the information provided above is true and correct. WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012; 31 U.S.C. §3729, 3802).

Lessor:

Signature

Print Name

Date

Head of Household/Lessee:

Signature

Print Name

Date

Form HUD-50164 9/2022