Form Hud-50059 - Owner'S Certification Of Compliance With Hud'S Tenant Eligibility And Rent Procedures
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Owner’s Certification of Compliance
U. S. Department of Housing
Landlord's Official Record of Certfication
And Urban Development
with HUD’s Tenant Eligibility
Office of Housing
OMB Approval Number 2502-0204
and Rent Procedures
Federal Housing Commissioner
(Exp. 12/31/2007)
Section A. Acknowledgements
Read this before you complete and sign this form HUD-50059
Public Reporting Burden. The reporting burden for this collection of information is estimated to average 55 minutes 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. Send comments regarding this burden estimate or any other aspect of this collection of
information including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (2502-
0204), Washington, DC 20503. The information is being collected by HUD to determine an applicant's eligibility, the recommended unit
size, and the amount the tenant(s) must pay toward rent and utilities. HUD uses this information to assist in managing certain HUD
properties, to protect the Government's financial interest, and to verify the accuracy of the information furnished. HUD or a Public Housing
Authority (PHA) may conduct a computer match to verify the information you provide. This information may be released to appropriate
Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatory investigators and prosecutors. However, the
information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. You must provide all of the
information requested, including the Social Security Numbers (SSNs) you, and all other household family members age six (6) years and
older, have and use. Giving the SSNs of all family members age six (6) years and older is mandatory; not providing the SSNs will affect
your eligibility. Failure to provide any information may result in a delay or rejection of your eligibility approval.
Privacy Act Statement. The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S.
Housing Act of 1937, as amended (42 U.S.C. 1437 et. seq.); the Housing and Urban-Rural Recovery Act of 1983 (P.L. 98-181); the
Housing and Community Development Technical Amendments of 1984 (P.L. 98-479); and by the Housing and Community Development
Act of 1987 (42 U.S.C. 3543).
Tenant(s)' Certification - I/We certify that the information in Sections C, D, and E of this form are true and complete to the best of my/our
knowledge and belief. I/We understand that I/we can be fined up to $10,000, or imprisoned up to five years, or lose the subsidy HUD pays
and have my/our rent increased, if I/we furnish false or incomplete information.
Owner's Certification - I certify that this Tenant's eligibility, rent and assistance payments have been computed in accordance with HUD's
regulations and administrative procedures and that all required verifications were obtained.
Warning to Owners and Tenants. By signing this form, you are indicating that you have read the above Privacy Act Statement and are
agreeing with the applicable Certification.
False Claim Statement. Warning: U.S. Code, Title 31, Section 3729, False Claims, provides a civil penalty of not less than $5,000 and
not more than $10,000, plus 3 times the amount of damages for any person who knowingly presents, or causes to be presented, a false or
fraudulent claim; or who knowingly makes, or caused to be used, a false record or statement; or conspires to defraud the Government by
getting a false or fraudulent claim allowed or paid.
Certification Summary from Page 2
Name of Project
Unit Number
Effective Date
Certification Type
Head of Household
Total Tenant Payment
Assistance Payment
Tenant Rent
Tenant Signatures
Head of Household
Date
Other Adult
Other Adult
Date
Date
Spouse / Co-Head
Date
Other Adult
Date
Other Adult
Date
Other Adult
Date
Other Adult
Date
Other Adult
Date
Other Adult
Date
Other Adult
Date
Other Adult
Date
Other Adult
Date
Other Adult
Date
Other Adult
Date
Owner/Agent Signature
Owner/Agent
Date
Anticipated Voucher Date
Check this box if Tenant is unable to sign for a legitimate reason
Previous versions of this form are obsolete.
Page 1 of __
form HUD-50059 (04/2005)
*F, *Future = future field
HB 4350.3 Rev 1
This form also replaces HUD-50059-D, -E, -F, & -G.
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