Form Omb Approval 2577-0169 - Request For Tenancy Approval Housing Choice Voucher Program

Download a blank fillable Form Omb Approval 2577-0169 - Request For Tenancy Approval Housing Choice Voucher Program in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Omb Approval 2577-0169 - Request For Tenancy Approval Housing Choice Voucher Program with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

U.S. Department of Housing

OMB Approval No. 2577-0169

Request for Tenancy Approval

(exp. 05/31/2004)

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 .08 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.

Eligible families submit this information to the Public Housing Authority (PHA) when applying for housing assistance under Section 8 of the U.S. Housing Act

of l937 (42 U.S.C. 1437f). The PHA uses the information to determine if the family is eligible, if the unit is eligible, and if the lease complies with program and

statutory requirements.

Responses are required to obtain a benefit from the Federal Government. The information requested does not lend itself to

confidentiality.

1. Name of Public Housing Agency (PHA)

2. Address of Unit (street address, apartment number, city, State & zip code)

3. Requested Beginning Date of Lease 4. Number of Bedrooms 5. Year Constructed 6. Proposed Rent

7. Security Deposit Amt.

8. Date Unit Available for Inspection

9. Type of House/Apartment

Single Family Detached

Semi-Detached / Row House

Manufactured Home

Garden / Walkup

Elevator / High-Rise

(Duplex)

(Townhouse)

(Four stories or less)

(Five stories or more)

10. If this unit is subsidized, indicate type of subsidy

Section 202

Section 221(d)(3)(BMIR)

Section 236 (Insured or noninsured)

Section 515 Rural Development

Home

Tax Credit

Other

(Describe Other Subsidy, Including Any State or Local Subsidy)

11. Utilities and Appliances

The owner shall provide or pay for the utilities and appliances indicated below by an “O”. The tenant shall provide or pay for the utilities and appliances indicated below

by a “T”. Unless otherwise specified below, the owner shall pay for all utilities and appliances provided by the owner.

Item

Specify fuel type

Provided by

Paid by

Heating

Natural gas

Bottle gas

Oil

Electric

Coal or Other

Cooking