Form Hud 52665 – Fill Out and Use

Public reporting burden for this collection of information is estimated to average .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.

This collection of information is authorized under Section 8 of the U.S. Housing Act of 1937 (42 U.S.C. 1437f). The information is used to standardize the information submitted to the receiving Public Housing Agency (PHA) by the initial PHA. In addition, the information is used for monthly billing by the receiving PHA.

Sensitive Information. The information collected on this form is considered sensitive and is protected by the Privacy Act. The Privacy Act requires that these records be maintained with appropriate administrative, technical, and physical safeguards to ensure their security and confidentiality. In addition, these records should be protected against any anticipated threats or hazards to their security or integrity which could result in substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom the information is maintained.

Privacy Act Statement. The Department of Housing and Urban Development (HUD) is authorized to collect the information required on this form by Section 8 of the U.S. Housing Act of 1937 (42 U.S.C. 1437f) and by the Housing and Community Development Act of 1987 (42 U.S.C. 3534(a)). Collection of this information, including SSN and annual income, is mandatory. The information is used to standardize the information submitted to the receiving Public Housing Agency (PHA) by the initial PHA. In addition, the information is used for monthly billing by the receiving PHA. The SSN is used as a unique identifier. HUD may disclose this information to Federal, State and local agencies when relevant to civil, criminal, or regulatory investigations and prosecutions. It will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. Failure to provide any of the information may result in delay or rejection of a family port.

Part I Initial PHA Information and Certification

Instructions: ThisportionoftheformistobecompletedbytheinitialPHAforafamilythatismovingoutoftheinitialPHA’sjurisdictionundertheportabilityprocedures.

Attachments:

a.A copy of the voucher issued by the initial PHA.

b.The most recent form HUD-50058 and copies of all related verification information for the current form HUD-50058. (Note: This is the latest form HUD-50058 completed for either an applicant, a new admission, an annual reexamination, or an interim redetermination. It is not the form HUD- 50058 that the initial PHA completes to report the portability move-out.)

Certification Statement:

The family is a current program participant or is not a current program participant but is income-eligible in the receiving PHA’s jurisdiction (see line 8 above), and the voucher was issued in accordance with the program regulations. Please issue the family a receiving PHA voucher that does not expire before 30 days from the expiration date indicated in Item 6 (the expiration date on the initial PHA’s voucher) for the appropriate bedroom size (based on the receiving PHA’s policies). I certify that the information contained on Part I of this form and the attached documents provided by my agency are true and correct. My agency will promptly reimburse amounts paid on behalf of the above family within 30 calendar days of receipt of Part II of this form and thereafter ensure that subsequent billing payments are received by your agency no later than the fifth working day of each month. Failure to comply with these payment due dates may result in the transfer of the family's voucher in accordance with program rules and regulations.

Part II-A Receiving PHA Information and Certification Instructions: The receiving PHA must always complete Part II-A.

(Note: include proration, if applicable. For example, if the proration factor for the year is 79% and your column B rate is $60, enter $47.4)

Certification Statement:

I certify that the information contained on Part II of this form and, if applicable, the attached form HUD-50058, is true and correct and that my agency will promptly remit any overpayment to your agency.

Form Submission Date (mm/dd/yyyy) _____________________

Part II-B Family Status, Initial HAP Contract Execution and Billing Changes After HAP Contract Execution

Instructions: for initial billings, Part II-B must be completed by the receiving PHA and received by the initial PHA within 90 days following the expiration date of the initial PHA’s voucher. For changes in the family status or the billing amount, Part II-B must be completed and sent within 10 working days from the effective date of the change. The receiving PHA does not submit the billing form each month unless the monthly amount due changes or both

PHAs agree to a different billing schedule that requires a more frequent billing submittal.

Check all statements below that apply:

1. The above family has failed to submit a request for tenancy approval for an eligible unit within the allotted time period. You may therefore reissue your voucher to another family and, if applicable, modify any records concerning local preference usage and income targeting requirements.

STOP. Do not complete remainder of form.

2. We have executed a HAP contract on behalf of the family and are absorbing the family into our own program effective

_________________(mm/dd/yyyy). You may reissue your voucher to another family. STOP. Do not complete remainder of form.

3. We executed a HAP contract on __________________ (mm/dd/yyyy) with an effective date of ________________ (mm/dd/yyyy) and are

billing your agency. The effective date of the family’s annual reexamination will be _________________ (mm/dd/yyyy). A copy of the new

form HUD-50058 is attached to this form. No other documentation is required. (Note: Receiving PHAs are required to complete and submit a form HUD-50058 for families moving into their jurisdiction under portability. The receiving PHA may elect to conduct a special recertification of the family to conform the dates of the unit inspection and recertification, but is not required to do so by HUD in order to complete the form HUD- 50058 for a portability move-in.) Complete line 10 below.

4. The HAP amount has changed effective ________________ (mm/dd/yyyy) for the family because of: (Check all applicable items. Complete

line 10 below).

annual recertification

interim/special recertification

change in payment standard

the family moved to another unit in the receiving PHA jurisdiction.

other: (specify)

(After this submission, billing amount is amount recorded on line c, unless otherwise notified by the receiving PHA.)

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