Housing Choice Voucher Program Inspection Form

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U.S. Department of Housing

Inspection Form

OMB Approval No. 2577-0169

and Urban Development

(exp. 9/30/2012)

Housing Choice Voucher Program

Office of Public and Indian Housing

Public reporting burden for this collection of information is estimated to average 0. 25 hours per response, including the time for reviewing instructions,

searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not

conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMB control number.

Privacy Act Statement. The Department of Housing and Urban Development (HUD) is authorized to collect the information required on this form by Section 8 of

the U.S. Housing Act of 1937 (42 U.S.C. 1437f). Collection of the name and address of both the family and the owner is mandatory. The information is used to

determine if a unit meets the housing quality standards of the section 8 rental assistance program. HUD may disclose this information to Federal, State and local

agencies when relevant to civil, criminal, or regulatory investigations and prosecutions. It will not be otherwise disclosed or released outside of HUD, except as

permitted or required by law. Failure to provide any of the information may result in delay or rejection of family participation.

Assurances of confidentiality are not provided under this collection.

This collection of information is authorized under Section 8 of the U.S. Housing Act of l937 (42 U.S.C. 1437f).

The information is used to determine if

a unit meets the housing quality standards of the section 8 rental assistance program.

PHA

Tenant ID Number

Date of Request (mm/dd/yyyy)

Inspector

Date Last Inspection (mm/dd/yyyy)

Date of Inspection (mm/dd/yyyy)

Neighborhood/Census Tract