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Get HUD-52517 2019-2024

Item Specify fuel type Provided by Heating Natural gas Bottle gas Oil Electric Coal or Other Cooking Water Heating Paid by Other Electric Water Sewer Trash Collection Air Conditioning Refrigerator Range/Microwave Other specify Previous editions are obsolete Page 1 of 2 form HUD-52517 09/2014 ref. Handbook 7420. Request for Tenancy Approval Housing Choice Voucher Program OMB Approval No. 2577-0169 exp. 09/30/2017 U.S. Department of Housing and Urban Development Office of Public and Indian Housing Public reporting burden for this collection of information is estimated to average. 08 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. The Department of Housing and Urban Development HUD is authorized to collect information required on this form by Section 8 of the U*S* Housing Act of 1937 42 U*S*C. 1437f. Collection of the data on the family s selected unit is mandatory. The information is used to determine if the unit is eligible for rental assistance. HUD may disclose this information to Federal State and local agencies when relevant civil criminal or regulatory investigations and prosecutions. It will not be otherwise disclosed or released ourside of HUD except as permitted or required by law. Failure to provide any of the information may result in delay or rejection of family voucher assistance. 1. Name of Public Housing Agency PHA 2. Address of Unit street address apartment number city State zip code 3. Requested Beginning Date of Lease 4. Number of Bedrooms 5. Year Constructed 6. Proposed Rent 7. Security Deposit Amt. 8. Date Unit Available for Inspection 9. Type of House/Apartment Single Family Detached Semi-Detached / Row House 10. If this unit is subsidized indicate type of subsidy Section 202 Section 221 d 3 BMIR Home Tax Credit Manufactured Home Garden / Walkup Section 236 Insured or noninsured Elevator / High-Rise Section 515 Rural Development Other Describe Other Subsidy Including Any State or Local Subsidy 11. Utilities and Appliances The owner shall provide or pay for the utilities and appliances indicated below by an O. The tenant shall provide or pay for the utilities and appliances indicated below by a T. Unless otherwise specified below the owner shall pay for all utilities and appliances provided by the owner. 8 Owner s Certifications. a* 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 the following section for most recently leased comparable unassisted units within the premises. Address and unit number Date Rented c* Check one of the following Lead-based paint disclosure requirements do not apply because this property was built on or after January 1 1978.

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