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Owner’s Certification of Compliance U. S. …

owner s Certification of Compliancewith HUD s Tenant Eligibilityand Rent ProceduresU. S. Department of HousingAnd Urban DevelopmentOffice of HousingFederal Housing CommissionerSection A. AcknowledgementsPublic Reporting 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 completingand reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection ofinformation 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 unitsize, and the amount the tenant(s) must pay toward rent and utilities.

Owner’s Certification of Compliance with HUD’s Tenant Eligibility and Rent Procedures U. S. Department of Housing And Urban Development Office of Housing

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Transcription of Owner’s Certification of Compliance U. S. …

1 owner s Certification of Compliancewith HUD s Tenant Eligibilityand Rent ProceduresU. S. Department of HousingAnd Urban DevelopmentOffice of HousingFederal Housing CommissionerSection A. AcknowledgementsPublic Reporting 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 completingand reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection ofinformation 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 unitsize, and the amount the tenant(s) must pay toward rent and utilities.

2 HUD uses this information to assist in managing certain HUDproperties, to protect the Government's financial interest, and to verify the accuracy of the information furnished. HUD or a Public HousingAuthority (PHA) may conduct a computer match to verify the information you provide. This information may be released in accordance withHUD s Computer Matching Agreement (CMA) between the Social Security Administration and the Department of Health and HumanServices. You must provide all of the information requested, including the Social Security Numbers (SSNs), unless exempted by 24 , you, and all other household members, have and use. Giving the SSNs of all household members, unless exempted by 24 , is mandatory; not providing the SSNs will affect your eligibility approval. Failure to provide any information may result in a delay orrejection of your eligibility this before you complete and sign this form HUD-50059 Privacy Act Department of Housing and Urban Development (HUD) is authorized to collect this information by the Act of 1937, as amended (42 1437 et.)

3 Seq.); the Housing and Urban-Rural Recovery Act of 1983 ( 98-181); theHousing and Community Development Technical Amendments of 1984 ( 98-479); and by the Housing and Community DevelopmentAct of 1987 (42 3543).Warning to Owners and signing this form, you are indicating that you have read the above Privacy Act Statement and areagreeing with the applicable Claim : Code, Title 31, Section 3729, False Claims, provides a civil penalty of not less than $5,000 andnot more than $10,000, plus 3 times the amount of damages for any person who knowingly presents, or causes to be presented, a false orfraudulent claim; or who knowingly makes, or caused to be used, a false record or statement; or conspires to defraud the Government bygetting a false or fraudulent claim allowed or 's Certification - I certify that this Tenant's eligibility, rent and assistance payments have been computed in accordance with HUD'sregulations and administrative procedures and that all required verifications were (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/ourknowledge and belief.

4 I/We understand that I/we can be fined up to $10,000, or imprisoned up to five years, or lose the subsidy HUD paysand have my/our rent increased, if I/we furnish false or incomplete of HouseholdName of ProjectUnit NumberCertification TypeEffective DateTotal Tenant PaymentTenant RentAssistance PaymentCertification Summary from Page 2 Previous versions of this form are form also replaces HUD-50059-D, -E, -F, & for submission to the Federal GovernmentLandlord's Official Record of CertificationOwner/AgentOwner/Agent SignatureDateHead of HouseholdDateSpouse / Co-HeadDateTenant SignaturesOther AdultDateOther AdultDateOther AdultDateOther AdultDateOther AdultDateOther AdultDateOther AdultDateOther AdultDateOther AdultDateOther AdultDateOther AdultDateOther AdultDateOther AdultDateOMBA pproval No. 2502-0204(Exp. 06/30/2017)Anticipated Voucher DateExtenuating Circumstances Codeform(06/2014)ref.

5 HB Rev. 1 HUD-50059 Total Annual IncomeLow Income LimitVery Low Income LimitExtremely Low Income LimitCurrent Income StatusEligibility Universe CodeSec. 8 Assist. 1984 IndicatorIncome Exception CodePolice / Security Tenant?Survivor of Qualifier?Household Citizenship EligibilityDeduction for DependentsChild Care Expense (work)Child Care Expense (school)3% of IncomeDisability ExpenseDisability DeductionMedical ExpenseMedical DeductionElderly Family DeductionTotal DeductionsAdjusted Annual IncomeTotal Tenant PaymentTenant RentUtility ReimbursementAssistance PaymentWelfare RentRent OverrideHardship ExemptionWaiver Type CodeEligibility Check Not RequiredExtenuating Circumstances CodeTTP Before OverrideSection F. Allowances & Rent B. Summary Information21. Unit Number22. No. of Bedrooms23. Building ID24. Unit Transfer Code25. Previous Unit Security Deposit27. 236 Basic/BMIR Rent28.

6 Market Rent29. Contract Rent30. Utility Allowance31. Gross Rent32. TTP at RAD ConversionSubsidy TypeSecondary Subsidy TypeProperty IDProject NumberContract NumberProject iMAX IDPlan of Action CodeHUD-Owned Project?Previous Housing CodeDisplacement Status Total Cash Value of Assets82. Actual Income from Assets83. HUD Passbook Rate84. Imputed Income from Assets85. Asset Income70. Total Employment Income71. Total Pension Income72. Total Public Assistance Income73. Total Other Income74. Total Non-Asset Income57. Expected Family Addition - Adoption58. Expected Family Addition - Pregnancy59. Expected Family Addition - Foster Children50. Family has Mobility Disability?51. Family has Hearing Disability?52. Family has Visual Disability?53. Number of Family Members54. Number of Non-Family Members55. Number of Dependents56. Number of Eligible Members60. Previous Head Last Name61. Previous Head First Name62.

7 Previous Head Middle Initial63. Active Full Cert. Effective Date64. Previous Head ID65. Previous Head Birth Date15. Project Move-In Date16. Certification Type17. Action Processed18. Correction Type19. EIV Indicator20. Prev. Subsidy versions of this form are form also replaces HUD-50059-D, -E, -F, & Effective Date13. Anticipated Voucher Date14. Next Recertification Dateform(06/2014)ref. HB Rev .1 HUD-50059 owner s Certification of Compliancewith HUD s Tenant Eligibilityand Rent ProceduresU. S. Department of HousingAnd Urban DevelopmentOffice of HousingFederal Housing CommissionerFor Personal Records ONLY - not forSubmission to the Federal GovernmentRecord for Landlords(Exp. 06/30/2017)Section C. Household Code(SSN) D. Income InformationSection E. Asset Type BenefitsClaim of HouseholdName of ProjectUnit NumberCertification TypeEffective DateTotal Tenant PaymentTenant RentAssistance PaymentFor Personal Records ONLY - not forSubmission to the Federal GovernmentRecord for Landlords(Exp.)

8 06/30/2017)Continuation Page: Use only when household members, income or asset items exceed the space allowed on page 2 Section C. Household InformationOwner s Certification of Compliancewith HUD s Tenant Eligibilityand Rent ProceduresU. S. Department of HousingAnd Urban DevelopmentOffice of HousingFederal Housing CommissionerSection D. Income InformationSection E. Asset InformationPrevious versions of this form are form also replaces HUD-50059-D, -E, -F, & (06/2014)ref. HB Rev. Code(SSN) Type BenefitsClaim No.


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