Housing Choice Voucher Program Inspection Checklist (Omb Approval No. 2577-0169)

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OMB Approval No. 2577-0169
Inspection Checklist
U.S. Department of Housing
(Exp. 9/30/2012)
and Urban Development
Housing Choice Voucher Program
Office of Public and Indian Housing
Public reporting burden for this collection of information is estimated to average 0.50 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 disp lays a valid OMB control
number. Assurances of confidentiality are not provided under this collection.
This collection of information is authorized under Section 8 of the U.S. Housing Act of l937 (42 U.S.C. 1437f). The informat ion is used to determine
if a unit meets the housing quality standards of the section 8 rental assistance program.
Name of Family
Tenant ID Number
Date of Request (mm/dd/yyyy)
Inspector
Neighborhood/Census Tract
Date of Inspection (mm/dd/yyyy)
Type of Inspection
Date of Last Inspection (mm/dd/yyyy)
PHA
Initial
Special
Reinspection
A. General Information
Housing Type
(check as appropriate)
Inspected Unit
Year Constructed (yyyy)
Single Family Detached
Full Address (including Street, City, County, State, Zip)
Duplex or Two Family
Row House or Town House
Low Rise: 3, 4 Stories,
IncludingGarden Apartment
High Rise; 5 or More Stories
Number of Children in Family Under 6
Manufactured Home
Congregate
Owner
Cooperative
Name of Owner or Agent Authorized to Lease Unit Inspected
Phone Number
Independent Group Resi-
dence
Single Room Occupancy
Address of Owner or Agent
Shared Housing
Other
B. Summary Decision On Unit (To be completed after form has been filled out)
Pass
Number of Bedrooms for Purposes
Number of Sleeping Rooms
of the FMR or Payment Standard
Fail
Inconclusive
Inspection Checklist
Item
Yes
No
In-
Final Approval
1. Living Room
No.
Pass
Fail
Conc.
Comment
Date (mm/dd/yyyy)
1.1
Living Room Present
1.2
Electricity
1.3
Electrical Hazards
1.4
Security
1.5
Window Condition
1.6
Ceiling Condition
1.7
Wall Condition
1.8
Floor Condition
Clear All Form Fields
* Room Codes: 1 = Bedroom or Any Other Room Used for Sleeping (regardless of type of room);
2 = Dining Room or Dining Area;
3 = Second Living Room, Family Room, Den, Playroom, TV Room;
4 = Entrance Halls, Corridors, Halls, Staircases; 5 = Addit ional Bathroom;
6 = Other
form HUD-52580 (3/2001)
Previous editions are obsolete
Page 1 of 7
ref Handbook 7420.8

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