HUD-52517: Request for Tenancy Approval, Housing Choice Voucher Program

Enter the Name of Public Housing Agency (PHA) in Box 1 and the Address of Unit (street address, unit #, city, state, zip code) in Box 2.

Enter the Requested Lease Start Date in Box 3.

Enter the Number of Bedrooms in Box 4, the Year Constructed in Box 5, the Proposed Rent in Box 6 and the Security Deposit Amt in Box 7.

Enter the Date Unit Available for Inspection in Box 8.

Box 9, Structure Type, lists Single Family Detached (one family under one roof), Semi-Detached (duplex, attached on one side), Rowhouse/Townhouse (attached on two sides), Low-rise apartment building (4 stories or fewer), High-rise apartment building (5+ stories) and Manufactured Home (mobile home).

In Box 10, if this unit is subsidized, indicate the type of subsidy: Section 202, Section 221(d)(3)(BMIR), Tax Credit, HOME, Section 236 (insured or uninsured), Section 515 Rural Development or Other (Describe Other Subsidy, including any state or local subsidy).

In Box 11, Utilities and Appliances, the owner shall provide or pay for the utilities/appliances indicated by an “O”. The tenant shall provide or pay for the utilities/appliances indicated by a “T”. Unless otherwise specified, the owner shall pay for all utilities and provide the refrigerator and range/microwave.

Specify the fuel type: for Heating, Natural gas, Bottled gas, Electric, Heat Pump, Oil or Other; for Cooking, Natural gas, Bottled gas, Electric or Other; for Water Heating, Natural gas, Bottled gas, Electric, Oil or Other. Enter O or T under Paid by.

Other Electric, Water, Sewer, Trash Collection, Air Conditioning and Other (specify).

Provided by: Refrigerator and Range/Microwave.

The program regulation requires the PHA to certify that the rent charged to the housing choice voucher tenant is not more than the rent charged for other unassisted comparable units.

Owners of projects with more than 4 units must complete Address and unit number, Date Rented and Rental Amount for most recently leased comparable unassisted units within the premises.

The owner (including a principal or other interested party) is not the parent, child, grandparent, grandchild, sister or brother of any member of the family, unless the PHA has determined (and has notified the owner and the family of such determination) that approving leasing of the unit, notwithstanding such relationship, would provide reasonable accommodation for a family member who is a person with disabilities.

Check one of the following:

Lead-based paint disclosure requirements do not apply because this property was built on or after January 1, 1978. The unit, common areas servicing the unit, and exterior painted surfaces associated with such unit or common areas have been found to be lead-based paint free by a lead-based paint inspector certified under the Federal certification program or under a federally accredited State certification program. A completed statement is attached containing disclosure of known information on lead-based paint and/or lead-based paint hazards in the unit, common areas or exterior painted surfaces, including a statement that the owner has provided the lead hazard information pamphlet to the family.

The undersigned certify under penalty of perjury that the information provided is true and correct.

Print or Type Name of Owner/Owner Representative and Print or Type Name of Household Head.

Sign on the Owner/Owner Representative Signature line and the Head of Household Signature line.

Enter the Business Address for the Owner/Owner Representative and the Present Address for the Head of Household.

Enter the Telephone Number and the Date (mm/dd/yyyy) for the Owner/Owner Representative, and the Telephone Number and the Date (mm/dd/yyyy) for the Head of Household.

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.