Fillable Voucher Housing Choice Voucher Program printable pdf download

U.S. Department of Housing

OMB No. 2577-0169

Voucher

(Exp. 04/30/2018)

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 0.05 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. 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 1937 (42 U.S.C. 1437f). The information is used to authorize a family to look for an eligible unit and specifies the size of the unit. The information also

sets forth the family's obligations under the Housing Choice Voucher Program.

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). Collection of family members’ names is mandatory. The information is used to authorize a family to look for

an eligible unit and specifies the size of the unit. The information also sets forth the family’s obligations under the Housing Choice Voucher Program. 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 family voucher issuance.

Please read entire document before completing form

Voucher Number

Fill in all blanks below. Type or print clearly.

1. Insert unit size in number of bedrooms. (This is the number of bedrooms for which the Family qualifies,

1 .

Unit Size

and is used in determining the amount of assistance to be paid on behalf of the Family to the owner.)

2. Date Voucher Issued (mm/dd/yyyy)

2. Issue Date (mm/dd/yyyy)

Insert actual date the Voucher is issued to the Family.

3. Date Voucher Expires (mm/dd/yyyy) Insert date sixty days after date

(mm/dd/yyyy)

3. Expiration Date

Voucher is issued. (See Section 6 of this form.)

4. Date Extension Expires (if applicable)(mm/dd/yyyy)

4. Date Extension Expires (mm/dd/yyyy)

(See Section 6. of this form)

5. Name of Family Representative

6. Signature of Family Representative

Date Signed (mm/dd/yyyy)

7. Name of Public Housing Agency (PHA)

Name and Title of PHA

Signature of PHA

Date Signed (mm/dd/yyyy)

Official

1. Housing Choice Voucher Program

2. Voucher

The public housing agency (PHA) has determined that the

A. When issuing this voucher the PHA expects that if the

above named family (item 5) is eligible to participate in

family finds an approvable unit, the PHA will have the

the housing choice voucher program. Under this program,

money available to enter into a HAP contract with the

the family chooses a decent, safe and sanitary unit to live

owner. However, the PHA is under no obligation to the

in. If the owner agrees to lease the unit to the family

family, to any owner, or to any other person, to approve a

under the housing choice voucher program, and if the

tenancy. The PHA does not have any liability to any party

PHA approves the unit, the PHA will enter into a housing

by the issuance of this voucher.

assistance payments (HAP) contract with the owner to

B. The voucher does not give the family any right to

make monthly payments to the owner to help the family

participate in the PHA’s housing choice voucher pro-

pay the rent.

gram. The family becomes a participant in the PHA’s

The PHA determines the amount of the monthly housing

housing choice voucher program when the HAP contract

assistance payment to be paid to the owner. Generally, the

between the PHA and the owner takes effect.

monthly housing assistance payment by the PHA is the

C. During the initial or any extended term of this voucher,

difference between the applicable payment standard and

the PHA may require the family to report progress in

30 percent of monthly adjusted family income. In

leasing a unit at such intervals and times as determined by

determining the maximum initial housing assistance

the PHA.

payment for the family, the PHA will use the payment

standard in effect on the date the tenancy is approved by

the PHA. The family may choose to rent a unit for more

than the payment standard, but this choice does not

change the amount of the PHA’s assistance payment. The

actual amount of the PHA’s assistance payment will be

determined using the gross rent for the unit selected by

the family.

Previous editions obsolete

Page 1 of 3

form HUD-52646 (04/2015)

ref. Handbook 7420.8

Voucher Housing Choice Voucher Program

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