Form 52670-A-PART-1 Schedule of Tenant ASsistance Payments Due

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

Special Claims for
Unpaid Rent / Damages
Instructions
Follow guidelines
in HUD Handbook
4350.3, Rev. 1
Chapter 9

Project name

Total amount
collected from
tenant

1.

Enter the security deposit you collected. Warning: If you did not collect
the required security deposit from the tenant that caused this claim,
stop! You cannot file this special claim.

2.

Enter the interest you earned on the security deposit

3.

Enter the money you collected for unpaid rents & damages
(from tenant, insurance, etc.)

4.

Total amount collected. Add lines 1-3

5.

Enter monthly contract rent at move-out for Section 8 or PAC units;
or the monthly operating rent for Section 202/811 PRAC

6.

Subtract line 4 from line 5 (equals maximum HUD liability). If this
amount is 0 or negative, stop! You have exceeded HUD's maximum.
You cannot file a claim for unpaid rent or damages.

7.

Enter rent charged but unpaid at move-out

8.

Subtract line 4 from line 7 (not less than 0)

9.

Enter the lesser of lines 6 & 8. Also, enter in column 3 on HUD 52670–
A, Part 2.

HUD's maximum liability

OMB Approval No. 2502-0182 (04/30/2009)

FHA project no.

Section 8/PAC/PRAC contract no.

Vacated Tenant name

Unit No.

Tenant vacant date

New Tenant's move-in date

Unpaid rent claim

HUD's remaining
liability applicable to damages

10. Subtract line 9 from line 6. If this amount is 0 or negative, stop! You
have exceeded HUD's maximum. You cannot file a claim for damages.
11. Enter cost to repair damage

12. Enter the remaining amount of the security deposit (line 4 minus line
7) This cannot be less than 0
13. Amount of damage exceeding the remaining security deposit (line 11
minus line 12) This cannot be less than 0
14. Enter the lesser of lines 10 & 13.
52670-A, Part 2.

Also, enter in column 4 on HUD

I certify: (a) I collected the appropriate security deposit according to Chapter 6,
Section 1, page 6-11, figure 6-3. (b) I billed tenants for unpaid rent or damages
and took all reasonable steps to collect the debt. (c) I determined 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.
Owner's printed name, signature, & date

HUDContract Administration Review
Claim approved.
Claim adjusted. Reason:
Claim denied. Reason:
Official's name, signature, & date

Claim ID: ____________

HUD will prosecute false claims & statements. Conviction may result in criminal and/or
civil penalties (18 U.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 (10/2002)
ref. Handbook 4350.3 Rev. 1

This form must be completed so HUD can pay owners an amount to
offset losses due to unpaid rent and/or tenant damages.
Regulations require that owners complete this form using statutory
formulas to determine unpaid rent and/or tenant damages.
The statutes requiring the submission are Section 8, United States
Housing Act (42 U.S.C. 1437f); Section 202 of the Housing Act of 1959
as amended by Section 801 of the National Affordable Housing Act (12
U.S.C. 1701(g); and Section 811 of the National Affordable Housing Act
(42 U.S.C. 8013). The regulations stipulating the submission are: 24
CFR 880, 881, 883, 884, 886, and 891. The administrative requirements
for these forms are provided in HUD Handbook 4350.3, Rev. 1 Chapter 9.
HUD does not promise confidentiality but will not disclose data on a
specific project or tenant. No questions of a sensitive nature are asked in
this form.
The Department of Housing & Urban Development is authorized to
collect this information by the U.S. Housing Act of 1937, as amended.
The owner/agent must provide all this information. The information
provided will be used by HUD to review accuracy of funds requested by
owner/agent for special claims payments for unpaid rent and/or tenant
damages.

Previous versions obsolete
Submit an original and two copies

HUD may disclose this information to Federal, state, and local agencies when
relevant to civil, criminal, or regulatory investigations and prosecutions.
Otherwise, it will not be disclosed or released outside of HUD, except as
permitted or required by law. Providing all information is mandatory, and failure
to provide information will affect participation in HUD programs.
Public reporting burden for this collection of information is estimated to
average 20 minutes 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
information unless that collection displays a valid OMB control number.

form HUD-52671-A (10/2002)
ref. Handbook 4350.3 Rev. 1