Full Text
Previous editions are obsolete 1 HUD-52517 (04/2023) Request for Tenancy Approval Housing Choice Voucher Program When the participant selects a unit, the owner of the unit completes this form to provide the PHA with information about the unit. The information is used to determine if the unit is eligible for rental assistance. 1. Name of Public Housing Agency (PHA) 2. Address of Unit (street address, unit city, state, zip code) 3. Requested Lease Start Date 4. Number of Bedrooms 5. Year Constructed 6. Proposed Rent 7. Security Deposit Amt 8. Date Unit Available for Inspection 9. Structure Type 10. If this unit is subsidized, indicate type of subsidy: □ Single Family Detached (one family under one roof) □ Semi-Detached (duplex, attached on one side) □ Rowhouse/Townhouse (attached on two sides) □ Low-rise apartment building (4 stories or fewer) □ High-rise apartment building stories) □Manufactured Home (mobile home) □Section 202 □Section 221(d)(3)(BMIR) □Tax Credit □HOME □Section 236 (insured or uninsured) □Section 515 Rural Development □ Other (Describe Other Subsidy, including any state or local subsidy) 11. Utilities and Appliances The owner shall provide or pay for the utilities/appliances indicated below by an The tenant shall provide or pay for the utilities/appliances indicated below by a Unless otherwise specified below, the owner shall pay for all utilities and provide the refrigerator and range/microwave. Item Specify fuel type Paid by Heating □Natural gas □Bottled gas □Electric □Heat Pump □Oil □Other Cooking □Natural gas □Bottled gas □Electric □Other Water Heating □Natural gas □Bottled gas □Electric □Oil □Other Other Electric Water Sewer Trash Collection Air Conditioning Other (specify) Provided by Refrigerator Range/Microwave U.S Department of Housing and Urban Development Office of Public and Indian Housing OMB Approval No. 2577-0169 exp. 04/30/2026 ---PAGE BREAK--- Previous editions are obsolete 2 HUD-52517 (04/2023) 12. Owner’s Certifications a. The program regulation requires the PHA to certify that the rent charged to the housing choice voucher tenant is not more than the rent charged for other unassisted comparable units. Owners of projects with more than 4 units must complete the following section for most recently leased comparable unassisted units within the premises. c. Check one of the following: □ Lead-based paint disclosure requirements do not apply because this property was built on or after January 1, 1978. □ The unit, common areas servicing the unit, and exterior painted surfaces associated with such unit or common areas have been found to be lead-based paint free by a lead-based paint inspector certified under the Federal certification program or under a federally accredited State certification program. □ A completed statement is attached containing disclosure of known information on lead-based paint and/or lead-based paint hazards in the unit, common areas or exterior painted surfaces, including a statement that the owner has provided the lead hazard information pamphlet to the family. 13. The PHA has not screened the family’s behavior or suitability for tenancy. Such screening is the owner’s responsibility. 14. The owner’s lease must include word-for-word all provisions of the HUD tenancy addendum. 15. The PHA will arrange for inspection of the unit and will notify the owner and family if the unit is not approved. Address and unit number Date Rented Rental Amount 1. 2. 3. b. The owner (including a principal or other interested party) is not the parent, child, grandparent, grandchild, sister or brother of any member of the family, unless the PHA has determined (and has notified the owner and the family of such determination) that approving leasing of the unit, notwithstanding such relationship, would provide reasonable accommodation for a family member who is a person with disabilities. OMB Burden Statement: The public reporting burden for this information collection is estimated to be 0.5 hours, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Collection of information about the unit features, owner name, and tenant name is voluntary. The information sets provides the PHA with information required to approve tenancy. Assurances of confidentiality are not provided under this collection. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions to reduce this burden, to the Office of Public and Indian Housing, US. Department of Housing and Urban Development, Washington, DC 20410. HUD may not conduct and sponsor, and a person is not required to respond to, a collection of information unless the collection displays a valid control number. Privacy Notice: The Department of Housing and Urban Development (HUD) is authorized to collect the information required on this form by 24 CFR 982.302. The form provides the PHA with information required to approve tenancy. The Personally Identifiable Information (PII) data collected on this form are not stored or retrieved within a system of record. I/We, the undersigned, certify under penalty of perjury that the information provided above is true and correct. WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil and administrative penalties. (18 U.S.C. 287, 1001, 1010, 1012; 31 U.S.C. §3729, 3802). Print or Type Name of Owner/Owner Representative Print or Type Name of Household Head Owner/Owner Representative Signature Head of Household Signature Business Address Present Address Telephone Number Date (mm/dd/yyyy) Telephone Number Date (mm/dd/yyyy)