HUD 50059 A Owner's Certification of Compliance - Partial Certificai

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)

A. Acknowledgements
Read this before you complete and sign this form HUD-50059 A. Public Reporting Burden. The public reporting burden for this collection of information is estimated to average 8 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. 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. I/We, the undersigned, certify under penalty of perjury that the information provided above is true, correct, and accurate. WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012, 1014; 31 U.S.C. §§3729, 3802).
B. Partial Certification
1. Name of Project			2. Project Number	3. Subsidy Type		4. Contract Number		5. Transaction Type
6. Head of Household (Last, First, Initial)			7. Unit Number	8. No. of Bedrooms		9. Building ID		10. Effective Date
11. Head ID Code (SSN)	12. Head Birth Date		13. Correction Type	14. EIV Indicator	15. Transaction Date Being Corrected			16. Anticipated Voucher Date
C. Move Outs				E. Gross Rent Changes and Unit Transfers
17. Move Out Code				22. Prev. Unit No. (UT's only)
18. Date of Death of Sole Member				23. Secondary Subsidy Type
19. Description				24. 236 Basic/BMIR Rent
D. Terminations				25. Market Rent
				26. Contract Rent
20. Termination Code				27. Utility Allowance
21. Description				28. Gross Rent
				29. TTP at RAD Conversion
				30. Total Tenant Payment
				31. TTP Before Override
				32. Tenant Rent
				33. Utility Reimbursement
				34. Assistance Payment
				35. Rent Override
				36. Security Deposit
F. Signatures
Head of Household		Date		Owner/Agent			Date

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