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

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