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

NOT for submission to the Federal Government
Landlord's Official Record of Certfication

Office of Housing
Federal Housing Commissioner

OMB Approval Number 2502-0204
(Exp. 06/30/2012)

Section A. Acknowledgements
Read this before you complete and sign this form HUD-50059
Public Reporting Burden. The reporting burden for this collection of information is estimated to average 55 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. Send comments regarding this burden estimate or any other aspect of this collection of
information including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (2502­
0204), Washington, DC 20503. The information is being collected by HUD 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. This information may be released to appropriate
Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatory investigators and prosecutors. However, the
information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. You must provide all of the
information requested, including the Social Security Numbers (SSNs) you, and all other household family members age six (6) years and
older, have and use. Giving the SSNs of all family members age six (6) years and older is mandatory; not providing the SSNs will affect
your eligibility. Failure to provide any information may result in a delay or rejection of your eligibility approval.
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).
Tenant(s)' Certification - I/We certify that the information in Sections C, D, and E of this form are true and complete to the best of my/our
knowledge and belief. 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 a civil penalty of not less than $5,000 and
not more than $10,000, 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

Unit Number

Effective Date

Certification Type

Head of Household

Total Tenant Payment

Assistance Payment

Tenant Rent

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
Anticipated Voucher Date

Check this box if Tenant is unable to sign for a legitimate reason
Previous versions of this form are obsolete.
This form also replaces HUD-50059-D, -E, -F, & -G.

Page 1 of __

form HUD-50059 (09/2008)

HB 4350.3 Rev 1

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

For Personal Records ONLY - not for
Submission to the Federal Government

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

Record for Landlords
(Exp. 05/31/2011)

Section B. Summary Information
1. Project Name

23. Unit Number
24. No. of Bedrooms
25. Building ID
26. Unit Transfer Code
27. Previous Unit No.
28. Security Deposit
29. Basic Rent
30. Market Rent
31. Contract Rent
32. Utility Allowance
33. Gross Rent

13. Effective Date
14. Anticipated Voucher Date
15. Next Recertification Date

2. Subsidy Type
3. Secondary Subsidy Type
4. Property ID
5. Project Number
6. Contract Number
7. Telecom Address
8. Plan of Action Code
9. HUD-Owned Project?
10. FIPS County Code
11. Previous Housing Code
12. Displacement Status

16. Project Move-In Date
17. Unit Move-In Date
18. Certification Type
19. Action Processed
20. Correction Type
21. Cert. Correction Date
22. Prev. Subsidy Type

Section C. Household Information
34.
No.

35.
Last Name

36.
First Name

37. 38. 39.
MI Rel. Sex

40.
Race

42.
Birth
Date

41.
Eth.

44.
43.
Special Student
Status Status

45.
ID Code
(SSN)

46.
47.
48.
49.
Elig. Alien Reg. Age at Work
Code Number
Cert. Codes

01
02
03
04
05
06
07
08
53. Number of Family Members
54. Number of Non-Family Members
55. Number of Dependents
56. Number of Eligible Members

50. Family is Mobility Impaired?
51. Family is Hearing Impaired?
52. Family is Visually Impaired?

57. Expected Family Addition - Adoption
58. Expected Family Addition - Pregnancy
59. Expected Family Addition - Foster Children

60. Previous Head Last Name
61. Previous Head First Name
62. Previous Head Middle Initial

63. Previous Effective Date
64. Previous Head ID
65. Previous Head Birth Date

Section E. Asset Information

Section D. Income Information
66.
Mbr.
No.

67.
Income Type Code

68.
Amount

70. Total Employment Income
71. Total Pension Income
72. Total Public Assistance Income
73. Total Other Income
74. Total Non-Asset Income

69.
SSN Benefits
Claim No.

75.
Mbr.
No.

76.
Description

77.
Status

78.
Cash Value

79.
Actual Yearly
Income

80.
Date
Divested

81. Cash Value of Assets
82. Actual Income from Assets
83. HUD Passbook Rate
84. Imputed Income from Assets
85. Asset Income

Section F. Allowances & Rent Calculations
86. Total Annual Income
87. Low Income Limit
88. Very Low Income Limit
89. Extremely Low Income Limit
90. Current Income Status
91. Eligibility Universe Code
92. Sec. 8 Assist. 1984 Indicator
93. Income Exception Code
94. Police / Security Tenant?
95. Survivor of Qualifier?
96. Household Assistance Status
Previous versions of this form are obsolete.
This form also replaces HUD-50059-D, -E, -F, & -G.

97. Deduction for Dependents
98. Child Care Expense (work)
99. Child Care Expense (school)
100. 3% of Income
101. Disability Expense
102. Disability Deduction
103. Medical Expense
104. Medical Deduction
105. Elderly Family Deduction
106. Total Deductions
107. Adjusted Annual Income
Page 2 of __

108. Total Tenant Payment
109. Tenant Rent
110. Utility Reimbursement
111. Assistance Payment
112. Welfare Rent
113. Hardship Exemption
114. Waiver Type Code

form HUD-50059 (09/2008)

HB 4350.3 Rev 1

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

For Personal Records ONLY - not for
Submission to the Federal Government

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

Record for Landlords
(Exp. 05/11/2011)

Name of Project

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
34.
No.

35.
Last Name

36.
First Name

37. 38. 39.
MI Rel. Sex

40.
Race

41.
Eth.

67.
Income Type Code

68.
Amount

Previous versions of this form are obsolete.
This form also replaces HUD-50059-D, -E, -F, & -G.

69.
SSN Benefits
Claim No.

43.
44.
Special Student
Status Status

45.
ID Code
(SSN)

46.
47.
48.
49.
Elig. Alien Reg. Age at Work
Code Number
Cert. Codes

Section E. Asset Information

Section D. Income Information
66.
Mbr.
No.

42.
Birth
Date

75.
Mbr.
No.

Page __ of __

76.
Description

77.
Status

78.
Cash Value

79.
Actual Yearly
Income

80.
Date
Divested

form HUD-50059 (09/2008)

HB 4350.3 Rev 1