form HUD-40072 (04/2005)
Page 1 of 2
Previous editions are obsolete
To be Completed
7. Effective date of eligibility
8. Date of referral to comparable
9. Date replacement dwelling inspected
by the Agency
for relocation assistance
replacement dwelling
and found decent, safe and sanitary
OMB Approval No. 2506-0016
(exp.07/31/2008)
(1) Monthly Rent and Estimated Average Monthly Utility Costs for Unit
That You Moved To (from Item 13, line (8), column (a))
(2) Monthly Rent and Estimated Average Monthly Utility Costs for Comparable
Replacement Dwelling (from Item 13, line (8), column (c)) (to be provided by Agency)
(3) Lesser of line (1) or (2) (If claim is for purchase assistance enter amount from line
(2))
(4) Total Tenant Payment (from Item 14, line (8) or as computed by PHA)
(5) Monthly Need (Subtract line (4) from line (3))
(6) Amount of Payment (Renters multiply amount on line (5) by 60;
Agency will determine purchase assistance amount)
(7) Cost of Security Deposit
(8) Cost of Credit Check
(9) Amount of Claim (Add lines (6), (7) and (8))
(10) Amount Previously Received, if any
(11) Amount Requested (Subtract line (10) from line (9))
$
$
$
$
$
$
Item
To Be Completed By Claimant
For Agency Use Only
6. Certification: I certify that this claim and supporting information are true and complete and that I have not been paid for these expenses from any other
source.
Signature(s) of Claimant(s) & Date
X
Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)
When Did You
When Did You Move
When Did You Move
Dwelling
Address
Rent/Buy This Unit?
To This Unit?
Out of This Unit?
3. Unit That You
Moved From
4. Unit That You
Moved To
1. Your Name(s) (You are the Claimant(s))
1a. Your Present Mailing Address(es)
1b. Your Telephone Number(s)
Privacy Act Notice: This information is needed to determine whether you are eligible to receive a payment to help you rent