Form Hud-52665 Family Portability Information Housing Choice Voucher Program

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U.S. Department of Housing

OMB Approval No. 2577-0169

Family Portability Information

and Urban Development

(exp. 04/30/2018)

Housing Choice Voucher Program

Office of Public and Indian Housing

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: This portion of the form is to be completed by the initial PHA for a family that is moving out of the initial PHA’s jurisdiction under the portability procedures.

1. Head of Household Name

2. Head of Household Social Security Number

3. Voucher Number (if applicable)

4. Bedroom Size

5. Issuance Date

6. Expiration Date

7. Date of Last Income Examination

(mm/dd/yyyy)

Annual income if new admission (not currently a voucher participant)

$ ___________________________

Date by which initial billing must be received (90 days following the expiration date of the initial PHA voucher) (mm/dd/yyyy)

__________________________

10. Initial PHA administrative fee rate

$ ____________________________

(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)

11. 80% of initial PHA ongoing administrative fee (line 10 x 0.8)

$ _____________________________

12. Receiving PHA to which family has been referred: ___________________________________________________.

Attachments:

A copy of the voucher issued by the initial PHA.

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.

Name of Certifying PHA Official __________________________________________

Type Full Name and Address of Initial PHA below

Signature

___________________________________________

Initial PHA Contact Name

___________________________________________

Phone Number

_________________

Email _______________________

Form Submission Date (mm/dd/yyyy) ____________________

form HUD-52665 (06/2016)