HUD-40058 Claim for Rental Assistance or Downpayment Assistance
In the case of wanting to request assistance with rent or down payment, the following form has to be completed and submitted along with all the necessary documents.
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form HUD-40058 ( 06/20 16) Page 1 of 3 Previous editions are obsolete
For Agency Name of Agency Project Name or Number Case Number Use Only
1a. Your Name(s) (You are the Claimant(s)) and Present Mailing Address 1b.Telephone Number(s)
3. Unit That You Moved From
4. Unit That You Moved To When Did You When Did You Move When Did You Move
Dwelling AddressRent/Buy This Unit? To This Unit? Out of This Unit?
Claim for Rental Assistance or
Down Payment Assistance
(49 CFR 24.402 and 24.401(f)) U.S. Department of Housing
and Urban Development
Office of Community Planning
and Development OMB Approval No. 2506-0016
(exp. 04/30/201 8)
2a. Have all members of the household moved to the same dwelling?
Yes No (If “No”, list the names of all members and the addresses
to which they moved in the Remarks Section.)
See page 3 for Public Reporting Burden and Privacy Act Statements before completing this form
2b. Do you (or will you) receive a Federal, State, or local housing program
subsidy at the dwelling you moved to? Yes No
Household Income
Claimant For Agency Use Only
(a) (b)
(1) Total number of persons in the household (See item 5(1) or (2))
(2) Annual Gross House- hold Income. (49 CFR
24.2(a)(14)). Enter
name of each house-
hold member with
income (include the
income of persons not
lawfully present in the
U.S.)
(3) Total Gross Annual Income (Sum of entries in item 6(2)) $ $
(4) URA low income limit for number of persons in item 6(1). If item 6(3) is greater than
item 6(4) - Family is not low-income. See 49 CFR 24.402 (b)(2)(ii) $
(5) Gross Monthly Income (Divide item 6(3) by 12) $$
(6) 30% of item 6(5) or "NA". (If gross annual income item 6(3) is greater than URA low income $ $
limit in item 6(4), enter "NA".)
$ $
Instructions: This claim form is for the use of families and individuals applying for rental or down payment assistance under the Uniform R elocation
Assistance and Real Property Acquisition Policies Act of 1970 (URA) and may also be used by a 90-day homeowner-occupant who ch ooses to rent rather than buy a replacement home. The Agency will help you complete the form. HUD also provides information on these require ments and other guidance materials on its website at www.hud.gov/relocation. If the full amount of your claim is not approved, the Agency will provide you with a written explanation of the reason. If you are not satisfied with the Agency's determination, you may appeal that determination. The Age ncy will explain how to make an appeal.Displaced persons must rent/purchase and occupy a decent, safe and sanitary replacement dwelling within one year from the date of displacement for replacement housing payment eligibility (see 24.402(a)(2)). All claims for payments must be filed no later th an 18 months from the date of displ acement (see 24.207(d)).
5. Certification of Legal Residency in the United States (Please read instructions below before completing this section.) Instructions: To qualify for relocation advisory services or relocation payments authorized by the Uniform Relocation Assistance and Real Pro perty Acquisition Policies Act, a “displaced person” must be a United States citizen or national, or an alien lawfully present in the United States. The certification below must be completed in order to receive any relocation benefits. (This certification may not have any standing with regard to applicable State laws providing relocation benefits.) Your signature on this claim form constitutes certification. See 49 CFR 24.208(g) & (h) for hardship exceptions.
Please address only the category (Individual or family) that describes your occupancy status. For item (2), please fill in the correct number of persons.
RESIDENTIAL HOUSEHOLDS
(1) Individual. (2) Family. I certify that I am: (check one) I certify that there are ______ persons in my household and that _____ a citizen or national of the United States ______ are citizens or nationals of the United States and _____ are aliens lawfully _____ an alien lawfully present in the United States. present in the United States.
6. Determination of Person’s Financial Means (Not applicable to 90-day homeowner-occupants who choose to rent. Enter NA in Item 6(6).)
) R U P K D V E H H Q U H Y L V H G 6 H H O D V W S D J H \f
form HUD-40058 ( 06/20 16) Page 2 of 3 Previous editions are obsolete
(2)
(3)
(4)
(5)
(6) Gross Monthly Rent and Utility Costs $$$$$
(add item 7(1) through (5))
(7) Monthly Housing Subsidy, if applicable $ $ $ $ $
(e.g., Housing Choice Voucher/Section 8, other)
Monthly Cost Unit That You Moved From Unit That You Moved To Comparable
(For Homeowner-Occupant, rent (Do not complete if claim is forReplacement
will be determined by the agency.) down payment assistance.) Dwelling
(a) (b) (c)(d) (e)
Claimant For Agency ClaimantFor Agency To Be Provided
Use Only Use Only By Agency
(1) Rent (The monthly rental amount due under the terms $$$$$
and conditions of occupancy. If utilities are not included
in rent, list in item 7(2) to (5))
(8) Net Monthly Rent and Utility Costs $$$$$
(subtract item 7(7) from item 7(6)) (Enter these
amounts on the appropriate lines in Item 8.) 7.
Determination of Rent and Average Monthly Utility Costs (See 49 CFR 24.402(b))
Instructions: To compute the payment, entries on line (8) must reflect all utility services. Therefore, identify on lines (2) through (5) each utility necessary to provide electricity,
gas, other heating/cooking fuels, water and sewer. In those cases where the utility service is not covered by the monthly rent, indicate the estimated out-of-pocket monthly cost.
In those cases where the utility service is covered by the monthly rent, enter “IMR” (In Monthly Rent). Determine the estimated average monthly cost of a utility service by dividing
the reasonable estimated yearly cost by 12. If a monthly housing program subsidy (e.g., Housing Choice Voucher/Section 8, other) has been provided, enter the applicable amount
on line (7).
8. Computation of Payment: If you are filing for down payment assistance, check this box and skip item 8(1).
To Be Completed
By Claimant
For Agency Use Only
(a) (b)
(1) Monthly Rent and Average Monthly Utility Costs for Unit That You Moved To (From item 7(8), Column (c)) $ $
( 2 ) Monthly Rent and Average Monthly Utility Costs for Comparable Replacement Dwelling (From item 7(8), Column (e)) (To be provided by the Agency)
(3) Lesser of item 8(1) or (2) (If claim is for down payment assistance, enter amount from item 8(2))
( 4 ) Monthly Rent and Average Monthly Utility Costs for Unit That You Moved From (From item 7(8), Column (a))
(For Homeowner-Occupants who choose to rent, to be determined by the agency.)
(5) 30% of Average Gross Monthly Household Income (From item 6(6), Column (a)). If item 6(6) is "NA", enter
"NA" here.
(6) Lesser of item 8(4) or 8(5)
(7) Monthly Need (Subtract item 8(6) from item 8(3))
( 8 ) Amount of Payment Claim (Amount on item 8(7) multiplied by 42) (For a Homeowner-Occupant who elects to
rent, this amount cannot exceed the difference between the aquisition cost of the displacement dwelling and
the cost of a comparable replacement dwelling. See form HUD-40057, item 5(5).) $$
(9) Amount Previously Received (if any)
(10) Amount Requested (Subtract item 8(9) from 8(8)) $$
9. Certification By Claimant(s): I certify that the information on this claim form and supporting documentation is true and complete and that I have not been
paid for these expenses by 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)
form HUD-40058 ( 06/20 16) Page 3 of 3
Remarks continued on a separate page? Yes N o
14. Recommended $
15. Approved $
Payment Action Amount of Payment SignatureName (Type or Print)Date (mm/dd/yyyy)
10. Effective date (mm/dd/yyyy) 11. Date (mm/dd/yyyy) replacement 12.Date(mm/dd/yyyy)
of eligibility for relocation dwelling inspected and found person occupied replacement
assistance decent, safe and sanitary dwelling
To be Completed
by the Agency
Remarks
13. Payment To Be Made In: Lump Sum Monthly Installments Other Installments
(only for down payment assistance) (specify in the R emarks Section)
( 1 2 7 ( 8 S G D W H G W R L Q F R U S R U D W H 0 $ 3 V W D W X W R U \ F K D Q J H V W R W K H 8 5 $ H I I H F W L Y H R Q 3 O H D V H Q R W H W K H F X U U H Q W
8 5 $ U H J X O D W L R Q V R I & ) 5 S D U W Z L O O E H U H Y L V H G L Q D I X W X U H 8 5 $ U X O H P D N L Q J W R U H I O H F W 0 $ 3 F K D Q J H V ) R U D G G L W L R Q D O
L Q I R U P D W L R Q R Q 0 $ 3 F K D Q J H V W R W K H 8 5 $ I R U + 8 ' S U R J U D P V D Q G S U R M H F W V U H I H U W R + 8 ' 1 R W L F H & 3 ' D W W K H
I R O O R Z L Q J Z H E V L W H K W W S S R U W D O K X G J R Y K X G S R U W D O G R F X P H Q W V K X G G R F " L G S G Q S G I \f
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