Request for Tenancy Approval Request for Tenancy Approval 1. Name of Public Housing Agency (PHA) 2. Address of Unit (street address, apartment number, city, State & zip code)3. Requested Beginning Date of Lease MM slash DD slash YYYY 4. Number of BedroomsPlease enter a number from 1 to 10.5. Year Built 6. Proposed Rent 7. Security Deposit Amount 8. Date Unit Available for Inspection MM slash DD slash YYYY 9. Type of House/Apartment Single Family Detached Semi-Detached / Row House Manufactured Home Garden / Walkup Elevator / High-Rise 10. If this unit is subsidized, indicate type of subsidy Section 202 Section 221(d)(3)(BMIR) Section 236 (Insured or noninsured) Section 515 Rural Development Home Tax Credit Other (Describe Other Subsidy, Including Any State or Local Subsidy) OtherOther (Describe Other Subsidy, Including Any State or Local Subsidy)11. Utilities and AppliancesThe owner shall provide or pay for the utilities and appliances indicated below by selecting “Owner”. The tenant shall provide or pay for the utilities and appliances indicated below by selecting“Tenant”.HeatingSpecify Fuel Type Natural gas Bottle gas Oil Electric Coal or Other Provided byOwnerTenantPaid byOwnerTenantCookingSpecify Fuel Type Natural gas Bottle gas Oil Electric Coal or Other Provided byOwnerTenantPaid byOwnerTenantWater HeatingSpecify Fuel Type Natural gas Bottle gas Oil Electric Coal or Other Provided byOwnerTenantPaid byOwnerTenantOther ElectricProvided byOwnerTenantPaid byOwnerTenantWaterProvided byOwnerTenantPaid byOwnerTenantSewerProvided byOwnerTenantPaid byOwnerTenantTrash CollectionProvided byOwnerTenantPaid byOwnerTenantAir ConditioningProvided byOwnerTenantPaid byOwnerTenantRefrigeratorProvided byOwnerTenantPaid byOwnerTenantRange/MicrowaveProvided byOwnerTenantPaid byOwnerTenantOtherSpecify Provided byOwnerTenantPaid byOwnerTenant12. Owner's Certificationsa. The program regulation requires the PHA to certify that the rent charged to the housing choice voucher tenant is not more than the rent charged for other unassisted comparable units. Owners of projects with more than 4 units must complete the following section for most recently leased comparable unassisted units within the premises.1. Address and unit number Date Rented MM slash DD slash YYYY Rental Amount 2. Address and unit number Date Rented MM slash DD slash YYYY Rental Amount 3. Address and unit number Date Rented MM slash DD slash YYYY Rental Amount The owner (including a principal or other interested party) is not the 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 leasing of the unit, notwithstand- ing such relationship, would provide reasonable accommodation for a family member who is a person with disabilities.c. Check one of the following: Lead-based paint disclosure requirements do not apply because this property was built on or after January 1, 1978. The unit, common areas servicing the unit, and exterior painted surfaces associated with such unit or common areas have been found to be lead-based paint free by a lead-based paint inspector certified under the Federal certification program or under a federally accredited State certification program. A completed statement is attached containing disclosure of known information on lead-based paint and/or lead-based paint hazards in the unit, common areas or exterior painted surfaces, including a statement that the owner has provided the lead hazard information pamphlet to the family. 13. The PHA has not screened the family’s behavior or suitability for tenancy. Such screening is the owner’s own responsibility. 14. The owner’s lease must include word-for-word all provisions of the HUD tenancy addendum. 15. The PHA will arrange for inspection of the unit and will notify the owner and family as to whether or not the unit will be approved.Name of Owner/Owner Representative Signature of Owner/Owner RepresentativeBusiness Address Telephone NumberDate MM slash DD slash YYYY
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