Voucher for Payment of Annual Contributions and Operating Statement

Voucher for Payment of US Department of Housing OMB Approval No. 2577-0282

Annual Contributions and and Urban Development (Exp. 03/31/2025)

Operating Statement Office of Public and Indian Housing

Housing Assistance Payments Program
Supplemental Reporting Form

Public reporting burden for this collection of information is estimated to average 1.50 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMB control number. Assurances of confidentiality are not provided under this collection. Authority for this collection of information is the Housing and Community Development Act of 1987. Housing Agencies (HAs) required to maintain financial reports in accordance with accepted accounting standards to permit timely and effective audits. The financial records identify the amount of annual contributions that are received and disbursed by HAs. Responses to the collection of information are required to obtain a benefit or to retain a benefit. The information requested does not lend itself to confidentiality.

HA Number:	HA Name: HA FYE:
Submission Type:	Original Submission Revised Submission Special Submission
Housing Choice Voucher Program – Utilization and Administrative Fee and Expense Reporting
Vouchers under lease on the First Day of the Month:
UML:
Rental Assistance Demonstration 1– Public Housing Conversion
Rental Assistance Demonstration 2- Mod Rehab, Rent Supp, RAP Conversion
Rental Assistance Demonstration 3 –PRAC Conversion
Litigation
Homeownership
New This Month
Moving To Work
One Year Mainstream – MTW
Family Unification – Non MTW
Family Unification – Pre2008 - MTW
Family Unification – 2008/Forward - MTW
Non-Elderly Disabled – Non-MTW
Non-Elderly Disabled – 2008/Forward - MTW
Portable Vouchers Paid
Hope VI
Tenant Protection
Enhanced Vouchers
Veterans Affair Supported Housing (VASH) Voucher
DHAP to HCV Vouchers Leased
Foster Youth to Independence
Mobility Demonstration
Housing Stability Vouchers
Emergency Transfer Vouchers for VAWA
All Other Vouchers
Total Vouchers
HAP Expenses:
Rental Assistance Demonstration 1– Public Housing Conversion
Rental Assistance Demonstration 2- Mod Rehab, Rent Supp, RAP Conversion
Rental Assistance Demonstration 3 – PRAC Conversion
Litigation
Homeownership
New This Month
Moving To Work
One Year Mainstream – MTW
Family Unification – Non MTW

Page 1 of 17 Form HUD-52681-B (03/2023)

Voucher for Payment of Annual Contributions and Operating Statement Housing Assistance Payments Program Supplemental Reporting Form

US Department of Housing and Urban Development Office of Public and Indian Housing

OMB Approval No. 2577-0282 (Exp. 03/31/2025)

HAP Expenses (cont.):
Family Unification – 2008/Forward - MTW
Non-Elderly Disabled – Non-MTW
Non-Elderly Disabled – 2008 Forward - MTW
Portable Vouchers Paid
Hope VI
Tenant Protection
Enhanced Vouchers
Veterans Affair Supported Housing (VASH) Voucher
DHAP to HCV Vouchers Leased
All Other Vouchers
MTW – Family Unification 2008/Forward HAP expenses after the First of the Month
MTW – Family Unification per-2008 HAP After the First of the Month
MTW – Non-Elderly Disabled 2008/Forward HAP Expenses after the First of the Month
MTW – VASH HAP Expenses after the First of the Month
MTW – One Year Mainstream HAP After the First of the Month
HCV – FSS Escrow Deposits
HCV – All Voucher HAP Expenses After the First of Month
Foster Youth to Independence
Mobility Demonstration
Housing Stability Vouchers
Emergency Transfer Vouchers for VAWA
MTW – Foster Youth to Independence HAP Expenses After the First of the Month
MTW – Mobility Demonstration HAP Expenses After the First of the Month
MTW – Housing Stability Vouchers HAP Expenses After the First of the Month
MTW – Emergency Transfer Vouchers for VAWA HAP Expenses After the First of the Month
Total Vouchers
Other Voucher Reporting Requirements:
UML:
HCV Number of Vouchers Under Lease (HAP Contract) on the last day of the month
HA Owned Units Leased – included in the units leased above
HCV New Vouchers Issued but not under HAP contract as of the last day of month
Portable Vouchers Administered (Port-In)
Mainstream
Number of PBVs under AHAP and not under HAP
Number of PBVs under HAP and Leased
Number of PBVs under HAP and not Leased
Number of PBVs under HAP and not Leased with vacancy payment and associated vacancy HAP expense

Page 2 of 17 Form HUD-52681-B (03/2023)

Voucher for Payment of Annual Contributions and Operating Statement Housing Assistance Payments Program Supplemental Reporting Form		US Department of Housing and Urban Development Office of Public and Indian Housing	OMB Approval No. 2577- 0282 (Exp. 03/31/2025)
	Mainstream – Number of New Vouchers Issued but not Under HAP Contract as of the last day of the month
	Housing Stability Vouchers – Number of New Vouchers Issued but not Under HAP Contract as of the last day of the month
	HAP Expenses:
	Portable Vouchers Administered (Port-In)
	Mainstream
	HCV HAP Spent on Permissive Deductions
	Mainstream HAP Spent on Permissive Deductions
	Number of PBVs under HAP and not Leased with vacancy payment and associated vacancy HAP expense
	Project Based Vouchers – Total HAP Expenses
	Mainstream – HAP Expenses After the First of the Month
	Mainstream – FSS Escrow Deposits
	Adjustment Funding- Per Unit Cost
	Inc ease Adjustment Funding- Shortfall
	Adjustment Funding- Per Unit Cost Increase MS Program
	Adjustment Funding- Shortfall MS Program

Page 3 of 17 Form HUD-52681-B (03/2023)

Voucher for Payment of Annual Contributions and Operating Statement Housing Assistance Payments Program Supplemental Reporting Form

US Department of Housing and Urban Development Office of Public and Indian Housing

OMB Approval No. 2577-0282 (Exp. 03/31/2025)

Memorandum Reporting:
UML:
Number of Hard to House Families Leased
HAP Expenses:
HCV – Fraud Recovery Total Collected this Month
Interest or other income earned this month from the investment of HAP funds and Net Restricted Assets
HCV – FSS Escrow Forfeitures
Portable HAP costs Billed and Unpaid – 90 Days or older
Mainstream – FSS Escrow Forfeitures this Month
Mainstream – Fraud Recovery Total Collected this Month
Non-HAP Spent on Permissive Deductions
Administrative Expenses:
HAP Expenses:
Non-MTW Administrative Expenses
Audit
Mainstream- Administrative Expenses
Mobility Demonstration Services Expenditures
Housing Mobility- Related Service Expenditures
Housing Mobility- Related Service Expenditures (MTW)
Financial
Status: HAP Expenses:
HCV – Unrestricted Net Position Funds (UNP) as of the Last Day of the Month
HCV – Restricted Net Position Funds (RNP) as of the Last Day of the Month
HCV – Cash/Investment as of the Last Day of the Month
Mainstream - Unrestricted Net Position Funds (UNP) as of the Last Day of the Month
Mainstream – Restricted Net Position Funds (RNP) as of the Last Day of the Month
Mainstream – Cash/Investment as of the Last Day of the Month
MTW:
HAP Expenses:
MTW – Public Housing Operating Subsidy Eligible Expenses
MTW – Capital Fund Eligible Expenses
MTW – Local, Non-Traditional (LNT) Program
MTW – HCV Administrative Fee Expenses
MTW – HCV Administrative Expenses Using HAP

Page 4 of 17 Form HUD-52681-B (03/2023)

Voucher for Payment of Annual Contributions and Operating Statement Housing Assistance Payments Program Supplemental Reporting Form

US Department of Housing and Urban Development Office of Public and Indian Housing

OMB Approval No. 2577-0282 (Exp. 03/31/2025)

Other - Unspent Funds Fund Source 1
Misc.:
Unspent Fund Source (HCV, CAP, OP or MTW) – 1
Type of Account – 1
Activity – 1
Funds Committed – 1
Type of Commitment – 1
Date of Commitment – 1 (MM/DD/YYYY)
Funds Obligated – 1
Type of Obligation – 1
Date of Obligation – 1 (MM/DD/YYYY)
Funds Expended from Commitment/Obligation – 1
Projected Date of Full Expenditure – 1 (MM/DD/YYYY)
Other - Unspent Funds Fund Source 2
Misc.:
Unspent Fund Source (HCV, CAP, OP or MTW) – 2
Type of Account – 2
Activity – 2
Funds Committed – 2
Type of Commitment – 2
Date of Commitment – 2 (MM/DD/YYYY)
Funds Obligated – 2
Type of Obligation – 2
Date of Obligation – 2 (MM/DD/YYYY)
Funds Expended from Commitment/Obligation – 2
Projected Date of Full Expenditure – 2 (MM/DD/YYYY)

Page 5 of 17 Form HUD-52681-B (03/2023)

Voucher for Payment of Annual Contributions and Operating Statement Housing Assistance Payments Program Supplemental Reporting Form

US Department of Housing and Urban Development Office of Public and Indian Housing

OMB Approval No. 2577-0282 (Exp. 03/31/2025)

Other - Unspent Funds Fund Source 3
Misc.:
Unspent Fund Source (HCV, CAP, OP or MTW) – 3
Type of Account – 3
Activity – 3
Funds Committed – 3
Type of Commitment – 3
Date of Commitment – 3 (MM/DD/YYYY)
Funds Obligated – 3
Type of Obligation – 3
Date of Obligation – 3 (MM/DD/YYYY)
Funds Expended from Commitment/Obligation – 3
Projected Date of Full Expenditure – 3 (MM/DD/YYYY)
Other - Unspent Funds Fund Source 4
Misc.:
Unspent Fund Source (HCV, CAP, OP or MTW) – 4
Type of Account – 4
Activity – 4
Funds Committed – 4
Type of Commitment – 4
Date of Commitment – 4 (MM/DD/YYYY)
Funds Obligated – 4
Type of Obligation – 4
Date of Obligation – 4 (MM/DD/YYYY)
Funds Expended from Commitment/Obligation – 4
Projected Date of Full Expenditure – 4 (MM/DD/YYYY)

Page 6 of 17 Form HUD-52681-B (03/2023)

Voucher for Payment of Annual Contributions and Operating Statement Housing Assistance Payments Program Supplemental Reporting Form

US Department of Housing and Urban Development Office of Public and Indian Housing

OMB Approval No. 2577-0282 (Exp. 03/31/2025)

Other - Unspent Funds Fund Source 5
Misc.:
Unspent Fund Source (HCV, CAP, OP or MTW) – 5
Type of Account – 5
Activity – 5
Funds Committed – 5
Type of Commitment – 5
Date of Commitment – 5 (MM/DD/YYYY)
Funds Obligated – 5
Type of Obligation – 5
Date of Obligation – 5 (MM/DD/YYYY)
Funds Expended from Commitment/Obligation – 5
Projected Date of Full Expenditure – 5 (MM/DD/YYYY)
Other - Unspent Funds Fund Source 6
Misc.:
Unspent Fund Source (HCV, CAP, OP or MTW) – 6
Type of Account – 6
Activity – 6
Funds Committed – 6
Type of Commitment – 6
Date of Commitment – 6 (MM/DD/YYYY)
Funds Obligated – 6
Type of Obligation – 6
Date of Obligation – 6 (MM/DD/YYYY)
Funds Expended from Commitment/Obligation – 6
Projected Date of Full Expenditure – 6 (MM/DD/YYYY)

Page 7of 1 7 Form HUD-52681-B (03/2023)

Voucher for Payment of Annual Contributions and Operating Statement Housing Assistance Payments Program Supplemental Reporting Form

US Department of Housing and Urban Development Office of Public and Indian Housing

OMB Approval No. 2577-0282 (Exp. 03/31/2025)

Other - Unspent Funds Fund Source 7
Misc.:
Unspent Fund Source (HCV, CAP, OP or MTW) – 7
Type of Account – 7
Activity – 7
Funds Committed – 7
Type of Commitment – 7
Date of Commitment – 7 (MM/DD/YYYY)
Funds Obligated – 7
Type of Obligation – 7
Date of Obligation – 7 (MM/DD/YYYY)
Funds Expended from Commitment/Obligation – 7
Projected Date of Full Expenditure – 7 (MM/DD/YYYY)
Other - Unspent Funds Fund Source 8
Misc.:
Unspent Fund Source (HCV, CAP, OP or MTW) – 8
Type of Account – 8
Activity – 8
Funds Committed – 8
Type of Commitment – 8
Date of Commitment – 8 (MM/DD/YYYY)
Funds Obligated – 8
Type of Obligation – 8
Date of Obligation – 8 (MM/DD/YYYY)
Funds Expended from Commitment/Obligation – 8
Projected Date of Full Expenditure – 8 (MM/DD/YYYY)

Page 8 of 17 Form HUD-52681-B (03/2023)

Voucher for Payment of Annual Contributions and Operating Statement Housing Assistance Payments Program Supplemental Reporting Form

US Department of Housing and Urban Development Office of Public and Indian Housing

OMB Approval No. 2577-0282 (Exp. 03/31/2025)

Other - Unspent Funds Fund Source 9
Misc.:
Unspent Fund Source (HCV, CAP, OP or MTW) – 9
Type of Account – 9
Activity – 9
Funds Committed – 9
Type of Commitment – 9
Date of Commitment – 9 (MM/DD/YYYY)
Funds Obligated – 9
Type of Obligation – 9
Date of Obligation – 9 (MM/DD/YYYY)
Funds Expended from Commitment/Obligation – 9
Projected Date of Full Expenditure – 9 (MM/DD/YYYY)
Other - Unspent Funds Fund Source 10
Misc.:
Unspent Fund Source (HCV, CAP, OP or MTW) – 10
Type of Account – 10
Activity – 10
Funds Committed – 10
Type of Commitment – 10
Date of Commitment – 10 (MM/DD/YYYY)
Funds Obligated – 10
Type of Obligation – 10
Date of Obligation – 10 (MM/DD/YYYY)
Funds Expended from Commitment/Obligation – 10
Projected Date of Full Expenditure – 10 (MM/DD/YYYY)

Page 9 of 17 Form HUD-52681-B (03/2023)

Voucher for Payment of Annual Contributions and Operating Statement Housing Assistance Payments Program Supplemental Reporting Form

US Department of Housing and Urban Development Office of Public and Indian Housing

OMB Approval No. 2577-0282 (Exp. 03/31/2025)

Other - Unspent Funds Fund Source 11
Misc.:
Unspent Fund Source (HCV, CAP, OP or MTW) – 11
Type of Account – 11
Activity – 11
Funds Committed – 11
Type of Commitment – 11
Date of Commitment – 11 (MM/DD/YYYY)
Funds Obligated – 11
Type of Obligation – 11
Date of Obligation – 11 (MM/DD/YYYY)
Funds Expended from Commitment/Obligation – 11
Projected Date of Full Expenditure – 11 (MM/DD/YYYY)
Expenses:
HAP Expenses:
Expense Amount 1
Expense Amount 2
Expense Amount 3
Expense Amount 4
Expense Amount 5
Misc.:
Expense Amount 1 Comment
Expense Amount 2 Comment
Expense Amount 3 Comment
Expense Amount 4 Comment
Expense Amount 5 Comment

Page 10 of 17 Form HUD-52681-B (03/2023)

Voucher for Payment of Annual Contributions and Operating Statement Housing Assistance Payments Program Supplemental Reporting Form

US Department of Housing and Urban Development Office of Public and Indian Housing

OMB Approval No. 2577-0282 (Exp. 03/31/2025)

MTW Other Expense Category
HAP Expenses:
MTW – Other PHA to identify the type of expense incurred Amount – 6
MTW – Other PHA to identify the type of expense incurred Amount – 7
MTW – Other PHA to identify the type of expense incurred Amount – 8
Misc.:
MTW – Other PHA to identify the type of expense incurred Amount – 6 Comment
MTW – Other PHA to identify the type of expense incurred Amount – 7 Comment
MTW – Other PHA to identify the type of expense incurred Amount – 8 Comment
Comments:
Misc.:
Comments
Disaster Voucher Program-1 (DVP):
Misc.
Disaster Comments - Mandatory when Other Fees are recorded
UML:
Disaster Name
Disaster Families Assisted
HAP Expenses:
Disaster Families Assisted
Disaster Security Deposit
Disaster Security Deposit Returned
Disaster Utility Deposit
Disaster Utility Deposit Returned
Disaster Administrative Expenditures
Disaster Broker Fee
Disaster Placement Fee
Disaster Service Connection Fee
Disaster Case Management Fee
Disaster Administrative Fee
Disaster Other Fees

Page 11 of 17 Form HUD-52681-B (03/202 3)

Voucher for Payment of Annual Contributions and Operating Statement Housing Assistance Payments Program Supplemental Reporting Form

US Department of Housing and Urban Development Office of Public and Indian Housing

OMB Approval No. 2577-0282 (Exp. 03/31/2025)

Disaster Voucher Program-2 (DVP):

Misc.:

Disaster Comments- Mandatory when Other Fees are recorded

UML:

Disaster Name

Disaster Families Assisted

HAP Expenses:

Disaster Families Assisted

Disaster Security Deposit

Disaster Security Deposit Returned

Disaster Utility Deposit

Disaster Utility Deposit Returned

Disaster Administrative Expenditures

Disaster Broker Fee

Disaster Placement Fee

Disaster Service Connection Fee

Disaster Case Management Fee

Disaster Administrative Fee

Disaster Other Fees

Disaster Voucher Program-3 (DVP):

Misc.:

Disaster Comments Mandatory when Other Fees are recorded

UML:

Disaster Name

Disaster Families Assisted

HAP Expenses:

Disaster Families Assisted

Disaster Security Deposit

Disaster Security Deposit Returned

Disaster Utility Deposit

Disaster Utility Deposit Returned

Disaster Administrative Expenditures

Disaster Broker Fee

Disaster Placement Fee

Disaster Service Connection Fee

Disaster Case Management Fee

Disaster Administrative Fee

Disaster Other Fees

Page 12 of 17 Form HUD-52681-B (03/2023)

US Department of Housing and Urban Development

Office of Public and Indian Housing

OMB Approval No. 2577-0282 (Exp. 03/31/2025)

Voucher for Payment of Annual Contributions and Operating Statement

Housing Assistance Payments Program Supplemental Reporting Form

Disaster Voucher Program-4 (DVP):

Misc.:

Disaster Comments Mandatory when Other Fees are recorded

UML:

Disaster Name

Disaster Families Assisted

HAP Expenses:

Disaster Families Assisted

Disaster Security Deposit

Disaster Security Deposit Returned

Disaster Utility Deposit

Disaster Utility Deposit Returned

Disaster Administrative Expenditures

Disaster Broker Fee

Disaster Placement Fee

Disaster Service Connection Fee

Disaster Case Management Fee

Disaster Administrative Fee

Disaster Other Fees

Page 13 of 17 Form HUD-52681-B (03/2023)

Voucher for Payment of Annual Contributions and Operating Statement Housing Assistance Payments Program Supplemental Reporting Form

US Department of Housing and Urban Development Office of Public and Indian Housing

OMB Approval No. 2577-0282 (Exp. 03/31/2025)

Emergency Housing Voucher Pr ogram- 1 (EHV):

UML:

Emergency Housing Vouchers

Emergency Housing Vouchers - Number of New Vouchers Issued but not U nder HAP Contract as of the last day of the month

HAP Expenses:

Emergency Housing Vouchers

Emergency Housing Vouchers - HAP Expenses After the First of the Month

Emergency Housing Vouchers - Admin Fees - Preliminary Fee Expenses

Emergency Housing Vouchers - Admin Fees - Placement/Issuance Fee Expenses

Emergency Housing Vouchers - Admin Fees - Ongoing Administrative Expenses

Emergency Housing Vouchers - Service Fee - Housing Search Assistance Expenses

Emergency Housing Vouchers - Service Fee - Security/Utility Deposit/ Rental Application/Holding Fee Expenses

Emergency Housing Vouchers -

Emergency Housing Vouchers -

Emergency Housing Vouchers -

Emergency Housing Vouchers -

Emergency Housing Vouchers - Restricted Net Position Funds (RNP) as of the Last Day of the Month

Emergency Housing Vouchers - Unrestricted Net Position Funds (UNP) as of the Last Day of the Month

Emergency Housing Vouchers - Cash/Investment as of the Last Day of the Month

Emergency Housing Vouchers - Fraud Recovery Total Collected this Month

FSS Escrow Forfeitures this Month

Service Fee - Owner Incentive Expenses

FSS Escrow Deposits

Service Fee - Other Eligible Expenses

Emergency Housing Vouchers HAP Spent on Permissive Deductions
Emergency Housing Vouchers Unexpended Service Fees

Page 14 of 17 Form HUD-52681-B (03/2023)

Voucher for Payment of Annual Contributions and Operating Statement Housing Assistance Payments Program Supplemental Reporting Form

US Department of Housing and Urban Development Office of Public and Indian Housing

OMB Approval No. 2577-0282 (Exp. 03/31/2025)

Emergency Housing Voucher Pr ogram- 2 (EHV):

UML:

Emergency Housing Vouchers

Emergency Housing Vouchers - Number of New Vouchers Issued but not U nder HAP Contract as of the last day of the month

HAP Expenses:

Emergency Housing Vouchers

Emergency Housing Vouchers - HAP Expenses After the First of the Month

Emergency Housing Vouchers - Admin Fees - Preliminary Fee Expenses

Emergency Housing Vouchers - Admin Fees - Placement/Issuance Fee Expenses

Emergency Housing Vouchers - Admin Fees - Ongoing Administrative Expenses

Emergency Housing Vouchers - Service Fee - Housing Search Assistance Expenses

Emergency Housing Vouchers - Service Fee - Security/Utility Deposit/ Rental Application/Holding Fee Expenses

Emergency Housing Vouchers -

Emergency Housing Vouchers -

Emergency Housing Vouchers -

Emergency Housing Vouchers -

Emergency Housing Vouchers - Restricted Net Position Funds (RNP) as of the Last Day of the Month

Emergency Housing Vouchers - Unrestricted Net Position Funds (UNP) as of the Last Day of the Month

Emergency Housing Vouchers - Cash/Investment as of the Last Day of the Month

Emergency Housing Vouchers - Fraud Recovery Total Collected this Month

FSS Escrow Forfeitures this Month

Service Fee - Owner Incentive Expenses

FSS Escrow Deposits

Service Fee - Other Eligible Expenses

Emergency Housing Vouchers HAP Spent on Permissive Deductions
Emergency Housing Vouchers Unexpended Service Fees

Page 15 of 17 Form HUD-52681-B (03/2023)

Voucher for Payment of Annual Contributions and Operating Statement Housing Assistance Payments Program Supplemental Reporting Form

US Department of Housing and Urban Development Office of Public and Indian Housing

OMB Approval No. 2577-0282 (Exp. 03/31/2025)

Emergency Housing Voucher Pr ogram- 3 (EHV):

UML:

Emergency Housing Vouchers

Emergency Housing Vouchers - Number of New Vouchers Issued but not U nder HAP Contract as of the last day of the month

HAP Expenses:

Emergency Housing Vouchers

Emergency Housing Vouchers - HAP Expenses After the First of the Month

Emergency Housing Vouchers - Admin Fees - Preliminary Fee Expenses

Emergency Housing Vouchers - Admin Fees - Placement/Issuance Fee Expenses

Emergency Housing Vouchers - Admin Fees - Ongoing Administrative Expenses

Emergency Housing Vouchers - Service Fee - Housing Search Assistance Expenses

Emergency Housing Vouchers - Service Fee - Security/Utility Deposit/ Rental Application/Holding Fee Expenses

Emergency Housing Vouchers -

Emergency Housing Vouchers -

Emergency Housing Vouchers -

Emergency Housing Vouchers -

Emergency Housing Vouchers - Restricted Net Position Funds (RNP) as of the Last Day of the Month

Emergency Housing Vouchers - Unrestricted Net Position Funds (UNP) as of the Last Day of the Month

Emergency Housing Vouchers - Cash/Investment as of the Last Day of the Month

Emergency Housing Vouchers - Fraud Recovery Total Collected this Month

FSS Escrow Forfeitures this Month

Service Fee - Owner Incentive Expenses

FSS Escrow Deposits

Service Fee - Other Eligible Expenses

Emergency Housing Vouchers HAP Spent on Permissive Deductions
Emergency Housing Vouchers Unexpended Service Fees

Page 16 of 17 Form HUD-52681-B (03/2023)

Voucher for Payment of Annual Contributions and Operating Statement Housing Assistance Payments Program Supplemental Reporting Form

US Department of Housing and Urban Development Office of Public and Indian Housing

OMB Approval No. 2577-0282 (Exp. 03/31/2025)

Comments:
Name of PHA Point of Contact:	POC Phone Number:	Ext:
Date Submitted:	Official HA Email Address:

Page 17 of 1 7 Form HUD-52681-B (03/2023 )