Fill - Voucher Housing Choice Voucher Program (Housing Authority of the County of Santa Cruz)

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

Fill in all blanks below. Type or print clearly.

Voucher Number

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.)

1. Unit Size

Date Voucher Issued (mm/dd/yyyy)

Insert actual date the Voucher is issued to the Family.

2. Issue Date (mm/dd/yyyy)

Date Voucher Expires (mm/dd/yyyy)

Insert date sixty days after date

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

3. Expiration Date (mm/dd/yyyy)

Date Extension Expires

(if applicable)(mm/dd/yyyy)

(See Section 6. of this form)

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

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

Official

Signature of PHA

Official

Date Signed (mm/dd/yyyy)

1. Housing Choice Voucher Program

A. The public housing agency (PHA) has determined that the

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

the housing choice voucher program. Under this program,

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

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

under the housing choice voucher program, and if the

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

assistance payments (HAP) contract with the owner to

make monthly payments to the owner to help the family

pay the rent.

B. The PHA determines the amount of the monthly housing

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

monthly housing assistance payment by the PHA is the

difference between the applicable payment standard and

30 percent of monthly adjusted family income. In

determining the maximum initial housing assistance

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.

2. Voucher

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

family finds an approvable unit, the PHA will have the

money available to enter into a HAP contract with the

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

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

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

by the issuance of this voucher.

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

participate in the PHA’s housing choice voucher pro-

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

housing choice voucher program when the HAP contract

between the PHA and the owner takes effect.

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

the PHA may require the family to report progress in

leasing a unit at such intervals and times as determined by

the PHA.

Previouseditions obsolete Page 1of 3

form

HUD-52646

(04/2015)

ref. Handbook 7420.8

Voucher

Housing Choice Voucher Program

U.S. Department of Housing

OMB No. 2577-0169

and Urban Development

Office of Public and Indian Housing

(Exp. 04/30/2018)

S A M P L E

3. PHA Approval or Disapproval of Unit or Lease

When the family finds a suitable unit where the owner is

willing to participate in the program, the family must give

the PHA the request for tenancy approval (on the form

supplied by the PHA), signed by the owner and the

family, and a copy of the lease, including the HUD-

prescribed tenancy addendum.

Note: Both documents

must be given to the PHA no later than the expiration

date stated in item 3 or 4 on top of page one of this

voucher.

B. 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.

The lease must include, word-for-word, all provisions of the

tenancy addendum required by HUD and supplied by the PHA.

This is done by adding the HUD tenancy addendum to the lease

used by the owner. If there is a difference between any provisions

of the HUD tenancy addendum and any provisions of the owner’s

lease, the provisions of the HUD tenancy addendum shall control.

D. After receiving the request for tenancy approval and a copy

of the lease,the PHA will inspect the unit. The PHA may not

give approval for the family to lease the unit or execute the

HAP contract until the PHA has determined that all the

following program requirements are met: the unit is eligible;

the unit has been inspected by the PHA and passes the

housing quality standards (HQS); the rent is reasonable; and

the landlord and tenant have executed the lease including the

HUD-prescribed tenancyaddendum.

E. If the PHA approves the unit, the PHA will notify the

family and the owner, and will furnish two copies of the

HAP contract to the owner.

1. The owner and the family must execute the lease.

2. The owner must sign both copies of the HAP con-

tract and must furnish to the PHA a copy of the

executed lease and both copies of the executed HAP

contract.

3. The PHA willexecute the HAP contract and return an

executed copy to the owner.

F. If the PHA determines that the unit or lease cannot be

approved for any reason, the PHA will notify the owner

and the family that:

1. The proposed unit or lease is disapproved for

specified reasons, and

2. If the conditions requiring disapproval are remedied

to the satisfaction of the PHA on or before the date

specified by the PHA, the unit or lease will be

approved.

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4. Obligations of the Family

A. When the family’s unit is approved and the HAP contract

is executed, the family must follow the rules listed below

in order to continue participating in the housing choice

voucher program.

B. The family must:

1. Supply any information that the PHA or HUD deter-

mines to be necessary including evidence of citizen-

ship or eligible immigration status, and information

for use in a regularly scheduled reexamination or

interim reexamination of family income and

composition.

2. Disclose and verify social security numbers and sign

and submit consent forms for obtaining information.

3. Supply any information requested by the PHA to

verify that the family is living in the unit or

information related to family absence from the unit.

4. Promptly notify the PHA in writing when the family

is away from the unit for an extended period of time

in accordance with PHA policies.

5. Allow the PHA to inspect the unit at reasonable times

and after reasonable notice.

6. Notify the PHA and the owner in writing before

moving out of the unit or terminating the lease.

7. Use the assisted unit for residence by the family. The

unit must be the family’s only residence.

8. Promptly notify the PHA in writing of the birth,

adoption, or court-awarded custody of a child.

9. Request PHA written approval to add any other

family member as an occupant of the unit.

10. Promptly notify the PHA in writing if any family

member no longer lives in the unit. Give the PHA a

copy of any owner eviction notice.

11. Pay utility bills and provide and maintain any

appliances that the owner is not required to provide

under the lease.

C. Any information the family supplies must be true and

complete.

D. The family (including each family member) must not:

1. Own or have any interest in the unit (other than in a

cooperative, or the owner of a manufactured home

leasing a manufactured home space).

2. Commit any serious or repeated violation of the

lease.

3. Commit fraud, bribery or any other corrupt or

criminal act in connection with the program.

4. 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.

5. Sublease or let the unit or assign the lease or transfer

the unit.

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S A M P L E

form

HUD

52646

(

04/2015)

Previous editions are obsolete Page 3 of 3 ref. Handbook 7420.8

6. Receive housing choice voucher program housing

assistance while receiving another housing subsidy,

for the same unit or a different unit under any other

Federal, State or local housing assistance program.

7. Damage the unit or premises (other than damage

from ordinary wear and tear) or permit any guest to

damage the unit or premises.

8. Receive housing choice voucher program housing

assistance while residing in a unit owned by a 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 rental of

the unit, notwithstanding such relationship, would

provide reasonable accommodation for a family

member who is a person with disabilities.

9. Engage inabuse of alcohol in a waythat threatens the

health, safety or right to peaceful enjoyment of the

other residents and persons residing in the

immediate vicinity of the premises

5. Illegal Discrimination

If the family has reason to believe that, in its search for suitable

housing, it has been discriminated against on the basis of age,

race, color, religion, sex, disability, national origin, or familial

status, the family may file a housing discrimination complaint

with any HUD Field Office in person, by mail, or by telephon

The PHA will give the family information on how to fill out and

file a complaint.

6. Expiration and Extension of Voucher

The voucher will expire on the date stated in item 3 on the top

of page one of this voucher unless the family requests an

extension

in writing and the PHA grants a written extension of

the voucher in which case the voucher will expire on the date

stated in item 4. At its discretion, the PHA may grant a family’s

request for one or more extensions of the initial term.

S A M P L E

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