HUD-52860-C Homeownership Addendum

Inventory Removal Application HUD-52860

U.S. Department of Housing and Urban Development Office of Public and Indian Housing

OMB Approval No. 2577-0075 (exp. XX/XX/XXXX)

Public reporting burden for this collection of information is estimated to average 3 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. HUD may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number. This general information is required to request HUD approval to remove public housing property (residential or non-residential) from public housing requirements, including use restrictions imposed under the the Annual Contributions Contract (ACC) and the Declaration of Trust (DOT)/Declaration of Restrictive Covenants (DoRC). PHAs may request such HUD approval under the following laws: demolition and disposition (Section 18 of the 1937 and 24 CFR 970); voluntary conversion (Section 22 of the 1937 Act and 24 CFR part 972); required conversion (Section 33 of the 1937 Act and 24 CFR part 972); homeownership (Section 33 of the 1937 Act and 24 CFR part 906); retentions under 2 CFR 200.311 (PIH Notice 2016-20); and eminent domain (PIH Notice 2012-8, or subsequent notice). Note: This form requests general information only and PHAs are required to submit an additional addendum for the specific type of proposed removal. This form in addition to the applicable addendum are collectively known as the SAC application since these applications are processed by HUD’s Special Applications Center (SAC). HUD will use this information to review PHA requests, as well as to track removals for other record keeping requirements. Responses to this collection of information are statutory and regulatory to obtain a benefit. The information requested does not lend itself to confidentiality. PHAs are required to submit this information electronically to HUD through this Inventory Removals Submodule of the Inventory Management System/PIH Information Center (IMS/PIC) system (or a later electronic system prescribed by HUD). IMS/PIC will assign each SAC application a “DDA” number. Note: This form does not apply to proposed removals (conversions) under HUD’s Rental Assistance Demonstration (RAD) program; and the instructions for RAD application submissions via IMS/PIC is provided and governed by a separate OMB-approved HUD form.

Section 1: General Information

1.Date of Application:
2.Name of Public Housing Agency (PHA):
3.PHA Identification Number:
4.PHA Address:
5.Contact Person Name at PHA:
6.Contact Person Phone No.:
7.Contact Person Email:

Section 2: Long-Term Possible Impact of Removal Action

1.Performance Funding Subsidy (PFS):	In FY      , this PHA received $      per unit in PFS funds. The PHA realizes that after this removal occurs, PFS funds will decrease by $ _      per year.
2. Capital Fund Program (CFP):	In FY      , this PHA received $      per unit in CFP funds. The PHA realizes that after this removal occurs, CFP funds will decrease by $       per year.

Section 3: PHA Plan, Board Resolution, Environmental Review and Local Government Consultation

1. Year of PHA Plan that includes the removal action: *Attach evidence that the removal action is included in the PHA Plan
2. Board Resolution Number that approves the removal action; and PHA’s submission of removal application to HUD: *Attach a copy of PHA Board Resolution
3. Board Resolution Date:
4. Check the box for the entity that conducted the Environmental Review (ER): *Attach a copy of HUD’s approval of the Environmental Review under 24 CFR part 50 or 58	HUD under 24 CFR part 50 Responsible Entity (RE) under 24 CFR part 58 Name of RE:       Date ER was conducted:
5. The PHA covers the following jurisdiction(s):
6. Date(s) of letter(s) of support from (local) government officials: *Attach copies of all letters of support from local government officials, along with a narrative description of the PHA’s consultation (if applicable)

Section 4: Description of Existing Development

1.Name of Development:
2. Development Number:
3. Date of Full Availability (DOFA):
4. Number of Residential Buildings:
5. Number of Non-Residential Buildings:
6. Date Constructed:
7. Is the Development Scattered Site?	Yes No
8. Number of Buildings (single family, duplexes, 3-plexes, 4-plexes, other):
9. Number of Types of Structures (row houses, walk-up units, high-rise unit)
10. Total Acres in Development:
11. Existing Unit Distribution (bedroom size; unit type (elderly, mixed, family); non-dwelling units) *Attach a description of the distribution of UFAS accessible units (bedroom size; unit type, e.g., mobility or sensory) and the distribution of units with other accessible features

Section 5: Description of Proposed Removal

1.Type of Removal Action(s) (e.g., Demolition, Disposition, Demolition and Disposition, DeMinimis Exception under Demolition, Voluntary Conversion, Required Conversion, Homeownership, Eminent Domain or Retention under 2 CFR part 200)
2. Proposed Action by Unit Type (e.g. bedroom size) * Attach a description of the distribution of UFAS accessible units (bedroom size; unit type, e.g., mobility or sensory) and the distribution of units with other accessible features.
3. Proposed Action by Building Type (e.g. residential & non-residential buildings) *If the removal action is for only a portion of property at a contiguous site, attach a site map.
4. Total Acreage Proposed for Removal (if applicable) *Attach a description of the land (e.g. survey, copy of the legal description) *If the removal action is for only a portion of property at a contiguous site, attach a site map. * Attach a copy of the Declaration of Trust (DOT)/Deed of Restrictive Covenant (DoRC) that is recorded against the property.
5. Estimated Value of the Proposed Property Was an independent appraisal conducted to determine the estimated Fair Market Value (FMV)? If yes, date of appraisal and name of appraiser: If not, describe other form of valuation used: *Attach an executive summary of the appraisal or other form of valuation.	$      Yes No Date:       Name:

6. Timetable
Activity	Estimated Number of Days After HUD Approval:
(a)Begin Relocation of Residents: N/A
(b)Complete Relocation of Residents: N/A
(c)Execute Contract for Removal (sales or demolition):

Section 6: Relocation

1.Number of Units Proposed for Removal that are Occupied as of the Submission Date of this SAC application:
2. Number of individual residents that the PHA estimates will be displaced by this removal action: *Attach a summary of the number of individual residents estimated to be displaced by race and national origin and a summary of households estimated by be displaced by who have a member who is a person with a disability.
3. Who will provide relocation counseling and advisory services to residents?	PHA staff Another Entity contracted by the PHA (Describe:      )
5. What comparable housing resources does the PHA expect to offer to displaced residents? *Attach a summary of the comparable housing resources that the PHA expects to offer and resident relocation preferences. Indicate how the PHA will identify and offer comparable housing to (a)displaced residents who have a family member who is a person with a disability; and (b) to displaced residents who are not eligible for Section 8 HCV assistance (e.g. because they are over-income).	Public Housing. If checked, number:       Section 8 HCV (existing resources If checked, number:       Section 8 HCV (new award of TPVs) (see question #8) If checked, number:       PBV Unit If checked, number:       Other (attach description) If checked, number:
6. What is the estimated costs of relocation and moving expenses (including advisory services)? *Attach a description of the relocation counseling and advisory services that the will be provided to residents who will be displaced by this action	$
7. What is the anticipated source of funds for relocation and moving expenses (including advisory services)?	Capital Funds Operating Funds Non-1937 Act Funds (describe:      )
8. Tenant Protection Vouchers (TPVs) – If the PHA is eligible to receive TPVs in connection with the proposed removal action how many TPVs is the PHA requesting? *Attach a brief explanation supporting the TPV request. See PIH Notice 2017-XX (HCV Funding Notice) and PIH Notice 2012-7 (or any successor notice)	Yes-Replacement TPVs If checked, number:       Yes-Relocation TPVs If checked, number:       No TPVs will be requested
9. Does the PHA administer its own Section 8 Voucher Program? If no, provide the name of another PHA that the PHA proposes will administer the TPVs for which the PHA may be eligible to receive.	Yes No

Section 7: Resident Consultation

1.Will any residents be displaced or otherwise affected by the proposed removal action? If yes, date(s) PHA consulted with residents? *Attach a narrative description of consultation process, along with supporting documentation (e.g., agenda, meeting notices; sign-in sheets; meeting minutes, print-out of written or email consultation)	Yes No Date(s):
2. Is there a Resident Council (at affected development)? If yes, name of Resident Council and dates PHA consulted it: *Attach a narrative description of consultation process, along with supporting documentation e.g. meeting notices; sign-in sheets; meeting minutes, print-out of written or email consultation)	Yes No Name:            Date(s):       N/A to removal action
3. Is there a Resident Council (PHA-wide jurisdiction)? If yes, name of Resident Council and dates PHA consulted it: *Attach a narrative description of consultation process, along with supporting documentation e.g. meeting notices; sign-in sheets; meeting minutes, print-out of written or email consultation)	Yes No Name:            Date(s):       N/A to removal action
4. Date(s) PHA consulted with the Resident Advisory Board (RAB) (as defined in 24 CFR 903.13) *Attach a narrative description of consultation process, along with supporting documentation e.g. meeting notices; sign-in sheets; meeting minutes, print-out of written or email consultation)	Date(s):            N/A to removal action
5. Did the PHA receive any written comments from residents or resident groups/organizations during the consultation process? *If yes, attach comments received, along with an evaluation by the PHA	Yes No

Section 8: PHA Certification of Compliance

Acting on behalf of the Board of Commissioners of the PHA, as its Chairman, Executive Director, or other authorized PHA official, I approve the submission of this SAC Application known as DDA #_________________ for removing public housing property from public housing use restriction, of which this document is a part, and make the following certifications, agreements with, and assurances to the Department of Housing and Urban Development (HUD) in connection with the submission of this SAC application and the implementation thereof:

1. All information contained in this SAC application (including all supporting documentation, attachments and required form HUD-52860 addendums) is true and correct as of today’s date;

2. The PHA will comply with all applicable fair housing and other civil rights requirements, including but not limited to HUD’s general non-discrimination and equal opportunity requirements listed at 24 CFR 5.105(a), as well as the duty to affirmatively further fair housing (AFFH) related to this SAC application. AFFH includes ensuring that the proposed inventory removal development is not in conflict with fair housing goals and strategies in my agency’s PHA or MTW Plan, and is consistent with my agency’s obligation to AFFH, certification and supporting activities. The PHA conducted the submission requirements of this SAC application (including removal justification; resident consultation, etc.) in conformity with Title VI of the Civil Rights Act of 1964, the Fair Housing Act, Section 504 of the Rehabilitation Act of 1973, title II of the Americans with Disabilities Act of 1990, state or local accessibility requirements, and other applicable civil rights laws. If HUD approves this SAC application, the PHA will carry out and implement this removal action (including relocation, if applicable), in conformity with all applicable civil rights requirements;

3. The removal action proposed in this SAC application does not violate any remedial civil rights order or agreements, compliance agreements, final judgments, consent decrees, settlement agreements or other court orders or agreements to which the PHA is a party;

4. If the PHA is a non-qualified PHA under the Housing and Economic Recovery Act of 2008 (HERA), it has complied with the PHA Plan requirements regarding demolition and disposition at 24 CFR part 903 and must specifically authorize the demolition or disposition action in their PHA Plan or in a Significant Amendment to that Plan. The description of the demolition or disposition action in the PHA Plan (or Significant Amendment) must be substantially identical to the description in the SAC application. If the PHA is a qualified PHA, the PHA certifies that it has discussed the removal action at a public hearing;

5. The PHA has conducted all applicable resident consultation and will conduct all relocation activities associated with this SAC application in a manner that is effective for persons with hearing, visual, and other communication-related disabilities consistent with Section 504 of the Rehabilitation Act of 1973 (24 CFR 8.6) and with 49 CFR 24.5, and as applicable, the Americans with Disabilities Act of 1990. . The PHA will take reasonable steps to ensure meaningful access to their programs and activities for persons who have limited ability to read, speak, or understand English – i.e., individuals who have limited English proficiency (LEP).

6. The PHA will comply with all applicable Federal statutory and regulatory requirements and other HUD requirements, including applicable PIH Notices, in carrying out the implementation this SAC application, as approved by HUD. The PHA specifically certifies that the property proposed for removal in this SAC application is in compliance with Declaration of Trust (DOT) or Declaration of Restrictive Covenants (DoRC) requirements.

7. ;

8. The PHA will comply with the terms and conditions of any HUD approval that HUD may issue for this SAC application, including requirements applicable to future use, record-keeping and reporting; and will specifically retain records of the SAC application and its implementing actions of HUD’s approval of this SAC application for a period of not less than 3 years following the last required action of HUD’s approval. The PHA further certifies that it will make such records available for inspection by HUD, the General Accountability Office and the HUD Office of Inspector General. If the PHA wants to make any material changes from what it described in its SAC application and/or HUD’s approval of the SAC application, it will request HUD approval for such changes, in accordance with applicable HUD guidance;

9. The PHA will not take any action to remove or otherwise operate the property proposed for removal outside of public housing requirements until it receives written approval of this SAC application from HUD;

10. If any units proposed for removal by this SAC application are subject to an Energy Performance Contracting (EPC), the PHA agrees to comply with additional instructions provided by HUD regarding the EPC and will not take any steps to implement this SAC application (if approved by HUD), without receiving confirmation from HUD that all applicable EPC requirements are satisfied;

11. If any units proposed for removal by this SAC application are subject to a Capital Fund Financing Plan (CFFP) or other Section 30 debt, the PHA agrees to comply with additional instructions provided by HUD regarding the CFFP or other Section 30 and will not take any steps to implement this application (if approved by HUD), without receiving confirmation from HUD that all applicable CFFP or other Section 30 requirements are satisfied; and

12. If the PHA is in the process of removing all of its public housing units from its ACC low-rent inventory through this or other SAC applications and/or other pending removal actions, including the Rental Assistance Demonstration (RAD) program, the PHA agrees to comply with additional instructions provided by HUD regarding the close-out of its public housing portfolio.

13. The proposed removal action does not conflict or interfere with the fulfillment of any remedial order or agreement in which the PHA is a party.

I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate. 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)

Name of Authorized Official:
Official Title:
Signature:
Date:

Form HUD-52860 Instructions:

This form request general information from PHAs about proposed removal actions under the following laws: demolition and disposition (Section 18 of the 1937 Act and 24 CFR part 970); voluntary conversion (Section 22 of the 1937 Act and 24 CFR part 972); required conversion (Section 33 of the 1937 Act and 24 CFR part 972); homeownership (Section 33 of the 1937 Act and 24 CFR part 906); retentions (PIH Notice 2016-20 and 2 CFR 200.311); and eminent domain (PIH Notice 2012-8, or replacement notice). This form is the first part of a SAC application. Although PHAs will be able to submit most of the information requested in this form electronically via the fields in the Inventory Removal Submodule of IMS/PIC (or a replacement system), PHAs must complete this form and upload it as an attachment if there is no field in the IMS/PIC SAC application for the requested information. Also, PHAs must upload the supporting documentation requested by this form in their electronic IMS/PIC SAC application. In addition, PHAs must complete and submit applicable addendums as indicated below as part of a SAC application. PHAs must refer to the applicable regulations, PIH notices and other program guidance noted above for detailed requirements on the submissions required for the specific removal action proposed in the SAC application.

Proposed Removal Action	Additional HUD Form Required
Section 18 Disposition and/or Demolition	HUD-52860-A
Section 18 Demolition Rehab Needs and Cost-Test	HUD-52860-B
Section 32 Homeownership	HUD-52860-C
Section 33 Required Conversion	HUD-52860-D
Section 22 Voluntary Conversion	HUD-52860-E
Eminent Domain	HUD-52860-F
Part 200 Retention	HUD-52860-G

Section 1: General Information

Some fields will automatically populate from IMS/PIC. If not, complete all fields.

Section 2: Long-term Impact of Removal Action

Complete this section.

Section 3: PHA Plan, PHA Board Resolution, Environmental Review and Local Government Consultation

Refer to the regulation, PIH Notice or other HUD guidance document for guidance on these requirements for the specific removal action proposed, but generally the following apply:

PHA Plan: PHAs must include the removal action in their PHA plan for all SAC applications. .

Board Resolution: PHAs must obtain a board resolution approving the removal action for all SAC applications. For demolitions and dispositions proposed under 24 CFR part 970, the board resolution must be dated after the date of resident and local government consultation.

Environmental Clearance: HUD will not process or approve a SAC application without evidence that the proposed removal action has received Environmental Clearance. This evidence will generally be a copy of a HUD signed Request for Release of Funds (RROF) HUD-7015.16 form (or subsequent form) for the proposed removal action (including future use, if known) to evidence an environmental review acceptable to HUD was completed under 24 CFR part 58. Unless HUD determines, in its sole discretion, to complete the environmental review itself under 24 CFR part 50, in which case the PHA must submit a copy of the letter by the local HUD Office of Public Housing, approving the environmental review under 24 CFR part 50. In some instances, evidence of Environmental Clearance may be a letter from the Responsibly Entity stating the activity was exempt or categorically excluded under 24 CFR part 58.

Local Government Consultation: PHAs must consult with their local government officials and obtain a letter of support for all SAC applications (except for eminent domain and and homeownership). For demolitions and dispositions proposed under 24 CFR part 970, PHAs must include a narrative description of its consultation with local government officials.

Section 4: Description of Existing Development

Most information should automatically populate from IMS/PIC information, except for Section 4, Line item 10 (Total Acres of the Development) which the PHA must complete. The development number should be the HUD development number. All development numbers are at least 8 characters long (and may be up to 11 characters for AMP developments).

Section 5: Description of Proposed Removal

Removal Action Type: PHAs must select removal action type as the first step to creating the electronic SAC application in IMS/PIC.

Property description (Unit, Building, Acreage): PHAs identify the property by development number(s) and buildings by their IMS/PIC building numbers (note: some non-dwelling buildings do not have IMS/PIC building numbers; and in this instance, should be identified in the SAC application as a building without an IMS/PIC number). PHAs provide the total acreage and physical address of the property proposed for removal. If the removal action includes land (i.e., not just buildings), PHAs should attach a description of the land (e.g. survey, copy of the legal description), along with a copy of the DOT/DoRC that is recorded against the property, if available. If the proposed removal action (including demolition) is for only a portion of the property at a contiguous site, PHAs must attach a site map.

Estimated Value of Property: Attach an independent appraiser’s appraisal summary or other valuation method.

Timetable: PHAs indicates the number of days after HUD approval of a SAC application that they estimate they will complete these activities.

Section 6: Relocation

PHAs complete this section for all proposed removal action where relocation will be required. In addition, PHAs may be required to complete additional relocation information in the applicable addendums (e.g. right of first refusal for homeownership applications; evidence of compliance with all applicable federal, state, and local laws for eminent domain actions).

Tenant Protection Vouchers (TPVs): Note that a PHA’s eligibility to receive TPVs in connection with the proposed removal action is based on statutory Appropriations laws, and other HUD guidance, including but not limited to PIH Notice 2016-04 (or any successor HCV Notice) and PIH Notice 2012-7 (or replacement notice).

Section 7: Resident Consultation

Refer to the regulation, PIH Notice or other HUD guidance document for guidance on resident consultation for the specific removal action proposed.

Section 8: PHA Certification of Compliance

The Executive Director, Board Chairperson, or other authorized agent of the PHA, should complete, sign and date the Certification and submit it (as a scanned PDF file) as part of its submission of the SAC application.

De Minimis Demolition

PHAs do not need HUD approval to demolish units under Section 18 de minimis authority. PHAs do need to submit information to HUD described at 970.7(a)(1), (2), (12), (13), and (15), which includes PHA plan, description of the property, board resolution, and environmental requirements. Thus, for purposes of de minimis demolitions, PHAs are submitting information and not a SAC application through this form.

form HUD-52860 (11/2016)

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