HUD 50059 Owner's Certification of Compliance with HUD's Tenant El

Owner’s Certification of Compliance with HUD’s Tenant Eligibility and Rent Procedures

U.S. Department of Housing and Urban Development Office of Housing Federal Housing Commissioner

NOT for submission to the Federal Government Landlord’s Official Record of Certification OMB Control No. 2502–0204 (exp. xx/xx/xxxx)

Section A. Acknowledgements
Read this before you complete and sign this form HUD-50059. Public Reporting Burden. The public reporting burden for this collection of information is estimated to average 30 minutes 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. Comments regarding the accuracy of this burden estimate and any suggestions for reducing this burden can be sent to U.S. Department of Housing and Urban Development, Office of the Chief Data Officer, 451 7th St SW, Room 8210, Washington, DC 20410–5000. Do not send completed forms to this address. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the collection displays a valid OMB control number. HUD collects this information to determine an applicant's eligibility, the recommended unit size, and the amount the tenant(s) must pay toward rent and utilities. HUD uses this information to assist in managing certain HUD properties, to protect the Government’s financial interest, and to verify the accuracy of the information furnished. HUD or a Public Housing Authority (PHA) may conduct a computer match to verify the information you provide, including through a computer matching agreement with the Social Security Administration, the Department of Health and Human Services, and other agencies. Pursuant to 42 U.S.C. 3543(a), you must provide all of the information requested, including the Social Security Numbers (SSNs) for you and all other household members, unless exempted by 24 C.F.R. § 5.216. Providing the SSNs of all household members, unless exempted by 24 C.F.R. § 5.216, is mandatory; failure to provide any information may result in a delay or rejection of your eligibility. Privacy Act Statement. The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937, as amended (42 U.S.C. 1437 et. seq.); the Housing and Urban-Rural Recovery Act of 1983 (P.L. 98–181); the Housing and Community Development Technical Amendments of 1984 (P.L. 98–479); and by the Housing and Community Development Act of 1987 (42 U.S.C. 3543). HUD will disclose this information to other Federal and state entities for computer matching purposes and for other purposes as described in the Systems of Records Notice for the Tenant Rental Assistance Certification System (TRACS) – HUD/HOU-11, available at hud.gov/privacy. Tenant(s)' Certification. I/We certify that the information in Sections C, D, and E of this form are true, complete, and accurate. I/We understand that I/we can be fined up to $10,000, or imprisoned up to five years, or lose the subsidy HUD pays and have my/our rent increased, if I/we furnish false or incomplete information. Owner's Certification. I certify that this Tenant's eligibility, rent and assistance payments have been computed in accordance with HUD's regulations and administrative procedures and that all required verifications were obtained. Warning to Owners and Tenants. By signing this form, you are indicating that you have read the above Privacy Act Statement and are agreeing with the applicable Certification. False Claim Statement. Warning: U.S. Code, Title 31, Section 3729, False Claims provides for a civil penalty plus 3 times the amount of damages for any person who knowingly presents, or causes to be presented, a false or fraudulent claim; or who knowingly makes, or caused to be used, a false record or statement; or conspires to defraud the Government by getting a false or fraudulent claim allowed or paid.
Certification Summary from Page 2
Name of Project			Effective Date	Certification Type	Anticipated Voucher Date
Head of Household			Total Tenant Payment	Assistance Payment	Tenant Rent
Unit Number			Extenuating Circumstances Code
Tenant Signatures
Head of Household	Date	Other Adult			Date
Spouse / Co-Head	Date	Other Adult			Date
Other Adult	Date	Other Adult			Date
Other Adult	Date	Other Adult			Date
Other Adult	Date	Other Adult			Date
Other Adult	Date	Other Adult			Date
Other Adult	Date	Other Adult			Date
Owner/Agent Signature
Owner/Agent					Date

Section B. Summary Information

1. Project Name 2. Subsidy Type 3. Secondary Subsidy Type 4. Property ID 5. Project Number 6. Contract Number 7. Project iMAX ID 8. Plan of Action Code 9. HUD-Owned Project? 10. Previous Housing Code 11. Displacement Status Code

12. Effective Date 13. Anticipated Voucher Date 14. Next Recertification Date 15. Project Move-In Date 16. Certification Type 17. Action Processed 18. Correction Type 19. EIV Indicator 20. Prev. Subsidy Type 21. RAD Conversion Tenant 22. RAD Phase-in Schedule 23. RAD Phase-in Year 24. RAD Prior TTP 25. TTP at RAD Conversion

26. Unit Number 27. Unit Group 28. No. of Bedrooms 29. Building ID 30. Unit Transfer Code 31. Previous Unit No. 32. Security Deposit 33. 236 Basic/BMIR Rent 34. Market Rent 35. Contract Rent 36. Utility Allowance 37. Gross Rent 38. Fixed Income Family?

Section C. Household Information

39. Mbr. No.

40. Last Name

41. First Name

42. MI

43. Rel.

44. Sex

45. Race/Eth.

46. Birth Date

47. Special Status

48. Stdnt. Stat.

49. ID Code (SSN)

50. SSN Excp

51. Ctzn Code

52. Alien Reg. Number

53. Age

54. Work Codes

01 02 03 04 05 06 07 08

55. Family has Mobility Disability? 56. Family has Hearing Disability? 57. Family has Visual Disability?

58. Number of Family Members 59. Number of Non-Family Members 60. Number of Dependents 61. Number of Eligible Members

62. Expected Family Addition - Adoption 63. Expected Family Addition - Pregnancy 64. Expected Family Addition - Foster Child/Adult

65. Previous Head Last Name 68. Active Full Cert. Effective Date 66. Previous Head First Name 69. Previous Head ID 67. Previous Head Middle Initial 70. Previous Head Birth Date

Section D. Income Information

Section E. Asset Information

71. Mbr. No.

72. Income Type Code

73. Verification Type

74. Amount

75. SSN Benefits Claim No.

81. Mbr.No.

82. Descrip-tion

83. Verification Type

84. Included in Net Family Assets?

85. Status

86. Cash Value

87. Asset Income

88. Actual/Imputed Income

89. Date Divest-ed

76. Total Employment Income 77. Total Pension Income 78. Total Public Assistance Income 79. Total Other Income 80. Total Non-Asset Income

90. Own Real Property? 91. Real Property Exemption? 92. Total Non-Enforcement of Asset Limit? 93. Limited Enforcement of Asset Limit? 94. Asset Limit Exception? 95. Meets Asset Limit Exception? 96. Total Cash Value of Net Family Assets 97. Actual Income from Net Family Assets 98. HUD Passbook Rate 99. Imputed Income from Net Family Assets 100. Total Asset Income

Section F. Allowances & Rent Calculations
101. Total Annual Income 102. Low Income Limit 103. Very Low Income Limit 104. Extremely Low Income Limit 105. Current Income Status 106. Eligibility Universe Code 107. Sec. 8 Assist 1984 Indicator 108. Income Exception Code 109. Police / Security Tenant? 110. Survivor of Qualifier? 111. Household Citizenship Eligibility	112. Deduction for Dependents 113. Child Care Expense (work) 114. Child Care Expense (school) 115. Child Care Expense Hardship 116.% of Income (Medical/Disability Expense Deduction) 117. % of Income Amount (Medical/Disability Expense Deduction) 118. Disability Expense 119. Disability Deduction 120. Health and Medical Care Expense 121. Health and Medical Care Expense Deduction 122. 5% of Income (Medical/Disability General Hardship) 123. General Hardship Deduction – Disability Expense 124. General Hardship Deduction – Health & Medical Care Expense 125. Elderly/Disabled Family Deduction 126. Total Deductions 127. Adjusted Annual Income	128. Total Tenant Payment 129. TTP Before Override 130. Tenant Rent 131. Utility Reimbursement 132. Assistance Payment 133. Welfare Rent 134. Rent Override 135. Rent Hardship Exemption 136. Waiver Type Code 137. Eligibility Check Not Required? 138. Extenuating Circumstances Code

Name of Project Head of Household

Unit Number

Effective Date

Certification Type

Head of Household

Total Tenant Payment

Assistance Payment

Tenant Rent

Continuation Page: Use only when household members, income or asset items exceed the space allowed on page 2

Section C. Household Information

39. Member Number

40. Last Name

41. First Name

42. MI

43. Rel.

44. Sex

45. Race/Ethnicity

46. RE Detail. .

47. Birth Date

48. Special Status

49. Student Status

59. ID Code (SSN)

51. SSN Exception

52. Ctzn. Code

53. Alien Reg. Number

54. Age

55. Work Codes

Section D. Income Information

Section E. Asset Information

71. Member Number

72. Income Type Code

73. Verification Type

74. Amount

75. SSN Benefits Claim No.

81. Member Number

82. Description

83. Verification Type

84. Included in Net Family Assets?

85. Status

86. Cash Value

87. Asset Income

88. Actual/Imputed Income

89. Date Divested

1

Previous versions of this form are obsolete form HUD-50059
ref. HB 4350.3 Rev. 1