U.S. Department of Housing
OMB No. 2577-0169
(exp. 07/31/2022)
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,
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
document before completing form
Voucher Number
Fill in all blanks below. Type or print clearly.
Unit Size
1. Insert
unit size
in number of bedrooms. (This is the number of bedrooms for which the Family qualifies,
and is used in determining the amount of assistance to be paid on behalf of the Family to the owner.)
2. Issue Date (mm/dd/yyyy)
Date Voucher Issued (mm/dd/yyyy)
Insert actual date the Voucher is issued to the Family.
3. Date Voucher Expires (mm/dd/yyyy)
must be at least sixty days after date issued.
Voucher is issued. (See Section 6 of this form.)
3. Expiration Date
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)
1. Housing Choice Voucher Program
2. Voucher
The public housing agency (PHA) has determined that the
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
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
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
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3. PHA Approval or Disapproval of Unit or Lease
4. Obligations of the Family
When the family finds a suitable unit where the owner is
A. When the family’s unit is approved and the HAP contract
willing to participate in the program, the family must give
is executed, the family must follow the rules listed below
the PHA the request for tenancy approval (on the form
in order to continue participating in the housing choice
supplied by the PHA), signed by the owner and the
voucher program.
family, and a copy of the lease, including the HUD-
prescribed tenancy addendum.
Note: Both documents
B. The family must:
must be given to the PHA no later than the expiration
Supply any information that the PHA or HUD deter-
date stated in item 3 or 4 on top of page one of this
mines to be necessary including evidence of citizen-
ship or eligible immigration status, and information
for use in a regularly scheduled reexamination or
The family must submit these documents in the manner
that is required by the PHA. PHA policy may prohibit the
family from submitting more than one request for tenancy
approval at a time.
Disclose and verify social security numbers and sign
and submit consent forms for obtaining information.
The lease must include, word-for-word, all provisions of the
Supply any information requested by the PHA to
tenancy addendum required by HUD and supplied by the PHA.
verify that the family is living in the unit or
This is done by adding the HUD tenancy addendum to the lease
information related to family absence from the unit.
Promptly notify the PHA in writing when the family
used by the owner. If there is a difference between any provisions
is away from the unit for an extended period of time
of the HUD tenancy addendum and any provisions of the owner’s
in accordance with PHA policies.
lease, the provisions of the HUD tenancy addendum shall control.
Allow the PHA to inspect the unit at reasonable times
D. After receiving the request for tenancy approval and a copy
and after reasonable notice.
of the lease, the PHA will inspect the unit. The PHA may not
Notify the PHA and the owner in writing before
give approval for the family to lease the unit or execute the
moving out of the unit or terminating the lease.
HAP contract until the PHA has determined that all the
following program requirements are met: the unit is eligible;
Use the assisted unit for residence by the family. The
the unit has been inspected by the PHA and passes the
unit must be the family’s only residence.
housing quality standards (HQS); the rent is reasonable; and
Promptly notify the PHA in writing of the birth,
the landlord and tenant have executed the lease including the
adoption, or court-awarded custody of a child.
HUD-prescribed tenancy addendum.
Request PHA written approval to add any other
E. If the PHA approves the unit, the PHA will notify the
family member as an occupant of the unit.
family and the owner, and will furnish two copies of the
10. Promptly notify the PHA in writing if any family
HAP contract to the owner.
member no longer lives in the unit. Give the PHA a
The owner and the family must execute the lease.
copy of any owner eviction notice.
The owner must sign both copies of the HAP con-
11. Pay utility bills and provide and maintain any
tract and must furnish to the PHA a copy of the
appliances that the owner is not required to provide
executed lease and both copies of the executed HAP
under the lease.
C. Any information the family supplies must be true and
The PHA will execute the HAP contract and return an
executed copy to the owner.
D. The family (including each family member) must not:
F. If the PHA determines that the unit or lease cannot be
Own or have any interest in the unit (other than in a
approved for any reason, the PHA will notify the owner
cooperative, or the owner of a manufactured home
and the family that:
leasing a manufactured home space).
1. The proposed unit or lease is disapproved for
Commit any serious or repeated violation of the
specified reasons, and
2. If the conditions requiring disapproval are remedied
Commit fraud, bribery or any other corrupt or
to the satisfaction of the PHA on or before the date
criminal act in connection with the program.
specified by the PHA, the unit or lease will be
Engage in drug-related criminal activity or violent
criminal activity or other criminal activity that
threatens the health, safety or right to peaceful
enjoyment of other residents and persons residing in
the immediate vicinity of the premises.
Sublease or let the unit or assign the lease or transfer
the unit.
Receive housing choice voucher program housing
5. Illegal Discrimination
assistance while receiving another housing subsidy,
If the family has reason to believe that, in its search for suitable
for the same unit or a different unit under any other
housing, it has been discriminated against on the basis of age,
Federal, State or local housing assistance program.
race, color, religion, sex, disability, national origin, or familial
Damage the unit or premises (other than damage
status, the family may file a housing discrimination complaint
from ordinary wear and tear) or permit any guest to
with any HUD Field Office in person, by mail, or by telephone.
damage the unit or premises.
The PHA will give the family information on how to fill out and
Receive housing choice voucher program housing
file a complaint.
assistance while residing in a unit owned by a parent,
6. Expiration and Extension of Voucher
child, grandparent, grandchild, sister or brother of
The voucher will expire on the date stated in item 3 on the top
any member of the family, unless the PHA has
of page one of this voucher unless the family requests an
determined (and has notified the owner and the
extension in writing and the PHA grants a written extension of
family of such determination) that approving rental of
the voucher in which case the voucher will expire on the date
the unit, notwithstanding such relationship, would
stated in item 4. At its discretion, the PHA may grant a family’s
provide reasonable accommodation for a family
request for one or more extensions of the initial term.
member who is a person with disabilities.
Engage in abuse of alcohol in a way that threatens the
health, safety or right to peaceful enjoyment of the
other residents and persons residing in the
Previous editions are obsolete
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