Fill - Free fillable Voucher Housing Choice Voucher Program PDF form

Voucher

Housing Choice Voucher Program

U.S. Department of Housing

and Urban Development

Office of Public and Indian Housing

OMB Approval No. 2577-0169

(Exp. 07/31/2022)

1. Unit Size

2. Issue Date (mm/dd/yyyy)

3. Expiration Date (mm/dd/yyyy)

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

Date Signed (mm/dd/yyyy)

Voucher Number

5. Name of Family Representative

7. Name of Public Housing Agency (PHA)

8. Name and Title of PHA Official 9. Signature of PHA Official

6. Signature of Family Representative

Please read entire document before completing form

Fill in all blanks below. Type or print clearly.

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. 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.)

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

(See Section 6. of this form.)

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,

Previous editions obsolete

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 program. 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.

3. PHA Approval or Disapproval of Unit or Lease

A. 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.

C. 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

Page 1 of 2

Los Angeles County Development Authority

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 agencymay

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.

form HUD-52646 (07/2019)

SAMPLE

Previous editions obsolete

Page 2 of 2

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

tenancy addendum.

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 contract and

must furnish to the PHA a copy of the executed lease and

both copies of the executed HAP contract.

3. The PHA will execute 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.

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 determines

to be necessary including evidence of citizenship 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.

form HUD-52646 (07/2019)

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.

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 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 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 telephone. 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.

SAMPLE

ah-subsidyestimation-(revised-10-02-2017)

Family Member Initial

Date

LOS ANGELES COUNTY DEVELOPMENT AUTHORITY

SUBSIDY ESTIMATION

PAYMENT STANDARDS

Payment standards are an estimate of the average cost of modest housing in the area. Each housing

authority has its own payment standards schedule. The payment standard for your family is typically the

bedroom size on your voucher, but will be smaller if you select a smaller unit.

Bedroom(s)

SRO

$924

$1232

$1522

$1852

$2462

$2684

$3086

$3489

$3892

$4294

HOW TO USE THE PAYMENT STANDARD

After the Los Angeles County Development Authority (LACDA) determines your minimum and maximum family

contribution (see below), the payment standard is used to calculate a maximum subsidy amount. With this

amount, LACDA determines your maximum allowable rent – the highest rent that is affordable for your family.

It is NOT a pre-approved amount that can be charged by an owner.

RENT REASONABLENESS

The LACDA cannot pay an owner more than what it calculates is the “going rent” in the area for comparable

units (similar type and size). Also, the owner can only charge you what he or she charges for unassisted

families (in similar units) in the same area or building.

the asking rent is too high compared to comparable units and the owner will not negotiate a lower rent, the

LACDA will not approve the unit for the program, even if the amount is affordable for your family, and you will

need to continue your search for a rental unit. The LACDA must approve all rents before the lease and

contract are signed.

FAMILY CONTRIBUTION / TOTAL TENANT PAYMENT (TTP)

HOH: TENANT ID #

• Minimum family contribution is the greater of:

 30% of your family’s monthly adjusted income;

 10% of your family’s monthly gross income; or

 The program’s minimum rent requirement of $50.

Minimum Family Contribution:

If the selected unit’s gross rent is at or below the payment standard, the family will pay the minimum family contribution.

• Maximum family contribution during the initial term of a

lease is 40% of your family’s monthly adjusted income, if

gross rent exceeds the payment standard.

Maximum Family Contribution:

(40% of monthly adjusted income)

• Maximum Subsidy is the most LACDA will pay towards

your family’s monthly rent. It is the applicable payment

standard minus your family’s minimum contribution.

Maximum Subsidy:

Payment Standard

Minus Minimum

Family Contribution —

$0.00

Equals Maximum Subsidy

$0.00

• Maximum Allowable Rent is the maximum amount of

rent that LACDA can approve for your family,

INCLUDING ALL UTILITIES (see Utility Allowance

Schedule). It is the family’s maximum contribution plus the

maximum subsidy.

Maximum Allowable Rent:

Maximum Family Contribution

$0.00

Plus Maximum Subsidy +

$0.00

Equals Maximum Allowable Rent

$0.00

SAMPLE

ah-subsidyestimation-(revised-10-02-2017)

Family Member Initial

Date

OS ANGELES COUNTY DEVELOPMENT AUTHORITY

SUBSIDY ESTIMATION

PRORATED ASSISTANCE

For eligible families that include one or more members who either do not have eligible immigration status

or who elect not to state that they have eligibility status, the amount of assistance is prorated, based on

the percentage of household members who are citizens or documented eligible immigrants.

• Proration Factor equals the

number of eligible household

members divided by the total

number of household members.

Proration Factor:

Number of eligible

household members

Divided by total number

of household members

Equals

Proration Factor

• Maximum Prorated Subsidy

equals the Maximum Subsidy

multiplied by the Proration

Factor.

Maximum Prorated Subsidy:

Maximum Subsidy

Multiplied by the

Proration Factor

Equals Maximum

Prorated Subsidy

$0.00

• Maximum Prorated Rent

equals the Maximum Family

Contribution plus the Maximum

Prorated Subsidy.

Maximum Prorated Rent:

Maximum Family

Contribution

Plus Maximum

Prorated Subsidy

Equals Maximum

Prorated Rent

$0.00

• Maximum Allowable Rent is

the greater of the Maximum

Prorated Rent or the Payment

Standard. (Circle the greater of

the two)

Maximum Allowable Rent:

Maximum

Prorated Rent

Payment Standard

Maximum

Allowable Rent

$0.00

SAMPLE

Los Angeles County Development Authority

CERTIFIED STATEMENT OF FAMILY OBLIGATIONS

All information requested by this agency is required to determine initial and/or continued eligibility for participation in a Housing Assistance

program.

You must follow all obligations if you wish to remain eligible for housing assistance.

The family shall:

1) Perform all its obligations under the program.

2) Report all income from all sources, as required by the Los Angeles County Development Authority (LACDA).

3) Report all changes in earned income and unearned income, assets, expenses, full-time student status, and family circumstances within

10 calendar days of the date the change takes effect. The composition of the assisted family residing in the unit must be approved by

LACDA. The family must:

a) Report the birth, adoption, or court-awarded custody of a child;

b) Request LACDA approval to add any other family member; and

c) Promptly notify LACDA when a family member no longer lives in the unit.

If LACDA gives approval, a live-in aid or a foster child may live in the unit. Failure to report changes, making false reports, and/or allowing

unauthorized people in the unit is cause for immediate termination from the program.

4) Supply any information that LACDA or the U.S. Department of Housing and Urban Development (HUD) determines is necessary in the

administration of the program. Information supplied by the family must be true and complete. Information includes any requested

certification, release, or other documentation, including:

a) Information requested by LACDA or HUD for use in a regularly scheduled or interim determination of family income and

composition;

b) Required evidence of citizenship or eligible immigration status; and

c) Disclosure and verification of Social Security numbers.

The family must also come to any scheduled briefing or counseling appointments.

5) Maintain the rental unit. The family is responsible for any violation of Housing Quality Standards resulting from:

a) Failure to pay for tenant-paid utilities;

b) Failure to furnish required stove and or refrigerator to be provided by family; or

c) Damage to the unit or grounds by the family or guests beyond normal wear and tear.

6) Allow LACDA to inspect the dwelling unit at reasonable times and after reasonable notice. You must be present at the inspection. Failure

to be present may result in the loss of your housing assistance subsidy.

7) Comply with the lease. The family may not commit any serious or repeated violations of the lease.

8) Notify LACDA and the owner, in writing, at least 30 days before vacating the dwelling unit. If the family receives an eviction or termination

notice from the owner, the family must contact its LACDA representative immediately and give a copy of the notice to LACDA.

9) Cooperate with LACDA in finding another unit when the family’s subsidy size changes.

10) Pay only the amount authorized by LACDA on the approved lease. Any amount paid by the family other than the authorized amount is

considered an illegal side payment and is cause for termination of the housing assistance subsidy. Additional payments for other

amenities may be authorized by LACDA only.

11) Use the dwelling unit primarily for residential purposes. The family shall use the dwelling unit as the family’s only place of residence, and

shall not sublease, let, or transfer the unit or assign the lease.

12) Supply any information or certification requested by LACDA to verify that the family is living in the unit or notify LACDA in advance if the

family will be absent from the unit for longer than 30 days, including the purpose of the absence. Even if the family absence is authorized,

the family must continue to pay the family portion of rent.

The family shall not:

1) Commit any fraud in connection with any housing assistance program.

2) Engage in drug-related criminal activity (including medical marijuana) or violent criminal activity on or near the premises of the unit, nor

shall any guests or invitees of the family engage in drug-related criminal activity (including medical marijuana) or violent criminal activity

on or near the premises of the unit.

3) Threaten or engage in abusive or violent behavior toward LACDA personnel.

4) Own or have any interest in the dwelling unit (other than in a manufactured home assisted under the program). If the owner is a

cooperative, the family may be a member in the cooperative.

5) Receive assistance under the program while receiving another housing subsidy for the same or another unit under any other federal,

state, or local housing assistance program (including other Section 8 programs).

6) Allow unauthorized persons to reside in the dwelling unit.

By signing below, I certify that I have read and understand the obligations listed above and agree to abide by them. I also

understand that if I, or any member of my family, fail to comply with one or more of these obligations, I may be terminated from

the program and lose my housing assistance subsidy.

Head of Household Name (PRINT) Head of Household (SIGNATURE) Date

HA-CERT FAMILY OBLIGATIONS (Revised 06-01-2020)

SAMPLE

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