Form Hud-40014-Pre-Rehabilitation Report July 1989 printable pdf download

U.S. Department of Housing

OMB Approval No. 2506-0080

Pre-Rehabilitation Report

(Exp. 1/31/2004)

and Urban Development

Rental Rehabilitation Program

Office of Community Planning

Cash and Management Information (C/MI) System

and Development

See Public Reporting Burden Statement on back

To be completed prior to project setup and the completed form sent to:

Check Appropriate Box

Date

Rental Rehab Program

Original

Revision

Ownership

Change

P.O. Box 23997, L'Enfant Plaza Station

Submission

Transfer

Owner's

Washington, DC 20026

Address

Part A: Call-In

Part A must be called in to HUD to set up or revise project accounts.

This completed form must be submitted to HUD immediately after a project setup call.

1 2 3 4 5 6 7

1. Project Number (Assigned by HUD)

2. Grantee/Local Recipient Number

3. Rental Rehabilitation Funds Requested

1 2 3 4 5 6 7

for Project by Fiscal Year

1 2 3 4 5 6 7

FY _____ $ __________________________

1 2 3 4 5 6 7

FY _____ $ __________________________

4. Address of Project to be Rehabilitated (include zip)

4a. County Code

FY _____ $ __________________________

(to be completed

FY _____ $ __________________________

by centralized

Street

City

State

Zip Code

States only )

Total Estimated Rehabilitation Costs

1 2 3 4 5 6 7 8 9

for Projects

1 2 3 4 5 6 7 8 9

Part B: Project Information

Mr.

Ms.

1a. Last Name of Owner

1 b. First Name of Owner

2. Name of Firm if Applicable

Mrs.

1c. Street

1d. City

3a. Name, Address and Phone Number (include area code) of person completing this form

1e. State

1f. Zip Code

1g. Phone Number (include area code)

3. Estimated Number

4. Is Property

5. Type of Ownership (check one)

6. High Cost Exception

7. Seismic Ordinance

of Residential Units

Owner

(1) Individual

(5) Cooperative

(1) Program Wide

Yes

in Project After

Occupied?

(2) Corporation

(6) Publicly Owned

(2) Project Specific

Rehab

(1) Yes

(3) Not for Profit

(7) Other (describe)

(3) None

(2) No

(4) Partnership

Total Number of Units

Part C: Characteristics of Households Residing in Project Prior to Rehabilitation

Prior to Rehab

Complete one line for each unit in the project. Enter one code only in each block.

Note: The sequence used below does not have to correspond in any way to how the unit occupied by each household is

distinguished from other units in the project.

Unit Characteristics

Household Characteristics

Number

Is Unit

Monthly Rent

Income

Race/Ethnicity

Size of

Female

Rental

Occupied

Including Utilities

(Percent of

of Head

Household

Head of

Assistance

Bedrooms

to Nearest Dollar

Area Median)

of Household

Household

0=Effic

1=Yes

0 = Uninhabitable ,

1=At or Below 50%

1=White, Not Hispanic Origin 1=Elderly

1=Yes

1=Section 8 Certificate

1=1 Bedrm

(Rental)

No Rental History or

2=51% - 80%

2=Black, Not Hispanic Origin 2=4 or less

2=No

2=Section 8 Voucher

2=2 Bedrm

2=No

Owner Occupied

3=Above 80%

3=American Indian/

3=5 or more

9=Not Available

4=Other Assistance

3=3 Bedrm

3=Owner

9=Not Available

Alaskan Native

4=Single

5=No Assistance

4=4 Bedrm

Occupied

4=Asian/Pacific Islander

9= Not

9=Not Available

5=5 or more

5=Hispanic

Available

Bedrms

9=Not Available

Use back of page as neces-

sary

Previous editions are obsolete

form HUD-40014 (7/89)

Form Hud-40014-Pre-Rehabilitation Report July 1989

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