Sample Unpaid Rent & Damages Claim - Arizona Department of ...

:ind this form at: www.azhousing.gov+Forms and Handbooks+Az Public
Otlher SPecial Claims Chrecklist
A
sing AutlhoritY-r5P"t;al Claims+
Public Housing AuthoritY
SPECIAL CLAIMS CHECKLIS
Tenant Damages, Unpaid Rent, and Charge,s
(For Vacancy Claims use Vacancy Claims Checklist, Fonn SC-6)
Property Name: LAKEWOOD APARTMENTS
Unit Nor: 05
Date Unit Reacly for Occupancy: 11/16/09
Submit the d,ocumentation listed below with each Speci:tl, C
Ulnpaid Rent and Other Charges along with Damages, alll mt
form. Glaim rnust be received within 180 days from the dlate
occupancy.
. lf you are cleriming
be calculated on the same
e unit was ready for
Tenant Damarges
Items with an asterisk ( - )will have been provided with the Vacancy
im if one was submitted.
g
E4
uLl
1. Conrpleted
*Form HUD 52670-A, Part 2, and Form HUD 52671-A.
2. *Copy of original lease and signed,move-in: 50059 as documenta
was collected
rr.
Copies of move-in and *move-out inspection reports. '
J;.
64 4t. *Security
deposit disposition information. You may use APHI\
following information is provided:
lhat appropriate security deposit
SC-5 or your own as long as the
E4
IZ
IZ
IZ
't7
.
B.
Move-out date
Amount of security deposit collected
Itemized charges for unpaid rent, damages or other charges
Breill

Speciarl Clalims tor
Unpairl Renrt / Damages
I nstructio ns Projectname
Follorw guidelinesr
in l-{LlD Harndbookr
4350.3, Rev. 1
Chapter €t
Total amount
collected from
tenant
LAKEWooD
APARTMENTS
U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Com
Enter the security deposit you collected.Warning: lf you did not
the required security deposit from the tenanthat caused this claim,
stop! You cannot file this special claim.
Enter the interest you earned on the security deposit
FHA project no.
1 23EH556
Tenant vacant date
11t10t2009
oME) Approval No. 2502-0182 (04/30/2012)
Section 8/PAC/PRAC contract no.
A220T90100'1
Unit No,
05
New Tenant's move-in date
12t28t2009
Enter the money you collected for unpaid rents & damages
(from tenant, insurance, etc)
Afl e )t, y
4. Total amount collected Add lines 1-3
HUD's maximum
liability
Unpaid rent claim
5. Enter monthly contract rent at move-out for Section 8 or PAC units;
or the monthly operating rent for Section 2021811 PRAC
6. Subtract Iine 4 from line 5 (equals maximum HUD liability)
amount is 0 or negative, stop! You have exceeded HUD's
You cannot file a claim for unpaid rent or damages.
7. Enter rent charged but unpaid at move-out
Sutrtract line 4 from line 7 (not less than 0)
436.42
Enter the lesser of lines 6 & 8 Also, enter in column 3 on
A, Part 2.
2L4 .00
10. Subtract line 9 from line 6. lf this amount is 0 or
have exceeded HUD's maximum. You cannot file
HUD's remaining ages.
liabililly applicable
to damages
11 Enter cost to repair damage
12. Enter the remaining amount of
7) l-his cannot be less than 0
13 Amounl ofdam
minus line 12)
14. Enter the lesser
52670-A, Part 2
I certify: (a) | collected the appropriate seei posit according to Chapter 6
Secti'cn 1, page 6-11, figLlre 6-3. (b) | bil ts for unpaid rent or damage
and tr3ok all reasotrable steps to collectthe debt. (c) ldetermined the damage
claim was due to the tenant's negligence or abuse. (d) All documentation will
be retained in the project's file for 3 years.
Ownen's printed name, signature, & date
J i'r,r'- Jtl '-s
f r>an/-
/ / '
\ota.P'{-'
a. Di,tt)
& 13. I'Also, enter in column 4 on HUD
.::'.:.-4.::l'
Administration Review
approVerC.
adjusted. Reason:
denied. lReason:
name, signature, & date
61.00
lFind this forrn at: wvyw.azhousing.gov .... Forms and Handbooks ...:
Az Publiic Ifousing Auth .... llpecial Claims .... Special Claims Form for
lUnpaidl )Damages
HUD r,vill prosecute false claims & statements. Conviction may result in criminal and/or
civil penalties (18l.J.S.C. Sections 1001, 1010, 1012;31 U.S C Sections 3729,3802).
Previous versions obsolete
Submit an original and two copies
form HUD-52671 -A (1012002)
ref. Handbook 4350.3 Rev. 1

Lakewood Apartments
1234F,. Lakeview Dr.
Nicetolive, A285777
Ph. 555/ 555-5555
Date: November 16,2009
To: John Smith
c/o Debbie Smith
1234 Washington Place
Somewhereville, AZ 09242
Dear Mr. Smith,
ITEMIZED LIST OF CHARG
Damages
Door repair
Replace light fixture $36.00
Sub Total $61.00
$2s.00
Rent & Other Charges Under Lease
Prior charge on ledger $33.00
Oct.
$243.00
Late fees.
$40.00
Nov.
$81.00
Keys not returned $5.00
Sub Total
$402.00
Legal Fees
Court Costs
$81.00
Attomey Fees $110.00
Sub Total
$191.00
Total owed by tenant
Total allowable to HUD
For Damages
For Unpaid rent
$6s4.00
$61.00 do not
$402.00 Ieft by tenunt
Legalfees

November t6,2009
Certified Mail/ Retum Receipt
John Smith
c/o Debbie Smith
1234 Washington Place
Sornewhereville, AZ 09242
RE: BALANCE DUE UPON MOVE OUT
Dear Mr. Smith:
On November 10, 2009 your move-out resulted in an amount ue of $ 5117.42. ,^.
breakdown of the charges and deposits made can be fourrd the enclosed Security
Deposit Disposition form and itemized list of charges. y'rs of ay's date this amount has
not been received. Please remit the total amount due on or bre Decennber 16. 2009.
If tlhe total amount is not paid on or before the due date, your
collectionr agency. This could have a negative impact onL
subsidized housing assistance in the future should the need
nt will be retlerred to a
ability to :receive
Sincerely,
fr
i illn c-
i /
Jane Jones
v
Director of Housing Programs,Lakewood Housine
t/ ,/

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12128109
ABC Collection Service
PO Box 000
Paymeback, GD 24931 -000
John Smith
c/o Debbie Smith
1234 Washington Pl.
Somewhereville" AZ 09242
Regarding your account with: Lakewood Housing Corpcr
Current Balance: $466.42
Account Nurnber:
0000.r50027
Reference Number:
05
Current Balance:
$466.42
The above matter has been assisned to this office for collecti . In order to settl.e thrs
matter, it is imperative you either call, make an appointment appear at this oflice, or
mail the entire balance. If you fail to do this, the debt witl be to the credit
reporting agencies of Arizona, which are affiliated nationLwi where it trecomers a part of
your credit record for a period of seven years. Make che,ck money ordler payarble to
ABC COLLECTION SERVICE. Please write the account ber on vour check.
In accordance with the Fair Debt Collection Practices Act, are hereby giving you 30
days to dispute the validity of this debt or any portion of it. e must have your dispute
in our office within 30 davs of this notice. If you do not , we will assume that the
debt is valid. If you do notify us in writing within 30 days, offrce will obtain and
send to you verification of this debt and amount due from the itor or a copy of any
judgment against you and mail it to you. If the current credi is differe:nt than the
original creditor, we will provide you with the name and of the original creditor.
This is a communication from a debt collector.
MONEY ORDERS OR CASHTE
ACCEPTED ONI,Y
CHIDCKS

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