Revised Aug. 2006
Request For Tenancy Doc
Page 2 of 2
Print or Type Name of Owner(s)
Print or Type Name of Household Head
Signature of Owner(s)
Signature (Household Head)
Business Address Present Address of Family (street address, apartment no., city, state, & zip code)
Telephone Number Date (mm/dd/yyyy) Telephone Number Date (mm/dd/yyyy)
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.
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, not withstanding such
relationship, would provide reasonable accommodation for a family member who is
a person with disabilities.
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 own 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 as to whether or not the unit will be approved.
If this unit is imanaged by an agent, please provide the following information (please print or type):
Name of Agent: _________________________________________________________________
Mailing Address:________________________________________________________________
Agent is authorized to execute Leases & HAP Contracts on owner's behalf? ____Yes ___No
Rate quality and condition of unit: ____ Above Average ____Average ____Below Average
Accessibility ___Hearing ___Sight ___Mobility Other _____________________________
UPON REQUEST, FAMILY INFORMATION REGARDING FAMILY TENANCY HISTORY AND
CRIMINAL ACTIVITY WILL BE RELEASED. CRIMINAL HISTORY MAY BE AVAILABLE AT:
http://casesearch.courts.state.md.us/inquiry/inquiry-index.jsp
City of Havre de Grace Rental Registration Number: ____________________
Owner's signature certifies all information provided is true and complete, that he/she has not
been barred from participating in any federally-funded housing programs.
