Housing Owner'S Certification

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U.S. Department of Housing
OMB Approval No. 2502-0182
Housing Owner's Certification
and Urban Development
(Exp. 06/30/2016)
and Application for Housing
Office of Housing
Assistance Payments
Federal Housing Commissioner
Part I - Contract Information
HUD/CA Use Only
1. Project Name:
2. FHA/EH/Non-Insured No.
3. Sec. 8/PAC/PRAC/Contract No.
Voucher Number:
4. Type of Subsidy:
5a. Management Agent's Name:
Date Received:
5b. EIN:
Date Paid:
Part II - Occupancy & Income Eligibility Information
7. Exceptions to Limitations on Admission of Low-Income Families (only for
6. General Occupancy Information (contract specific):
Sec. 8 contracts effective on or after 10/1/81):
Total Units in contract
Project-based exceptions in use
Number of Units receiving subsidy under this contract
Project-based exceptions allocated
Number of units abated under this contract
Tenant-based exceptions in use
Number of Units vacant under this contract
Total exceptions (line b + line c)
Number occupied by Market Rent Tenants
Date Field Office last changed allocations for
project-based exceptions (mm/dd/yy)
Note: 6a must equal 6b + 6c + 6d + 6e
Part III - Breakdown of Assistance Payment Requested
HUD/CA Use Only
9. Number of
8. Type of Assistance
Units in Billing
Amount Approved
Amount Requested
Regular Tenant Assistance Payments for (mo./yr.):
Adjustments to Regular Tenant Assistance Payments
Section 8 Special Claims for Unpaid Rent
Section 8 Special Claims for Tenant Damages
iii. Section 8 Special Claims for Vacancies
iv. Section 8 Special Claims for Debt Service
Miscellaneous Accounting Requests
Repayment Agreements
Total Subsidy Authorized under instructions in Handbook 4350.3 Rev. 1
Part IV - Distribution of Subsidy Earned (HUD/CA Use Only)
Amount Approved
Part V - Owner's Certification I certify that: (1) Each tenant’s eligibility and
12. Applied to HUD-held mortgage
assistance payment was computed in accordance with HUD’s regulations,
administrative procedures, and the Contract, and are payable under the Contract;
(2) all required inspections have been completed; (3) the units for which
13. Applied to debts owed by mortgagor
assistance is billed are decent, safe, sanitary, and occupied or available for
occupancy; (4) no amount included on this bill has been previously billed or paid;
14. Paid to Project
(5) all the facts and data on which this request for payment is based are true and
correct; and (6) I have not received and will not receive any payments or other
15. $
of the amount in item F, part III was
consideration from the tenant or any public or private source for the unit beyond
released from the Residual Receipts Account.
that authorized in the assistance contract or the lease, except as permitted by
HUD. Upon request by the Department of Housing and Urban Development, its
Printed Name, Date, Title & Phone No. (include area code) & Signature:
duly authorized representative, or the Comptroller General of the United States, I
will make available for audit all books, records and documents related to tenants’
eligibility for, and the amount of, assistance payments. Warning: HUD will
prosecute false claims & statements. Conviction may result in criminal and/or civil
penalties (18 U.S.C. Sections 1001, 1010, 1012; 31 U.S.C. Sections 3729, 3802).
form HUD-52670 (05/2014)
Previous editions are obsolete
Submit an Original and two copies
ref. HB 4350.3 Rev. 1


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