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Moving to Work Housing Choice Voucher Program Housing Authority of the City of Atlanta, Georgia

Housing Program

Request for Tenancy Approval


Program Move

Property and Participant Information

Participant Name Participant SSN Landlord Name Vendor Number Yes No Zip

Does the Participant require Reasonable Accommodations based on a disability? Property Name

(Subdivision or Complex Name)

Unit Address City # of Bedrooms # of Bathrooms Yes

(Bedroom size must match Voucher size)


Sq. Feet

Year Built

Total # of Units in Building/Complex No If Yes, when?


Has this property/unit been rented to Participants in the AHA Program before? Type of Residence (select one): Type of Ownership (select one): Proposed Monthly Rent $

If this unit is subsidized, indicate type of subsidy: Tax Credit Other (describe other subsidy, including any state or local subsidy)

Detached or Semi-Detached: Multi-Family: Single Owner

High-Rise w/ Elevator


Townhouse / Villa

Low-Rise Apartment

Condominiums Proposed Move-In Date

Other (describe):

Amenities Provided at the Property

Washer/Dryer Porch Off-Street Parking Other W/D hookups Balcony Dishwasher Deck Garbage Disposal Lawn Maintenance Carport Parking - # spaces: Ceiling Fan Pest Control Pool Alarm System

Garage Parking - # spaces:

Utilities and Appliances

Unless otherwise specified below, the owner shall pay for all utilities and appliances provided by the owner.

Item Type Heating Cooking Water Heating Other Electric Water Sewer Air Conditioning Refrigerator Range/Microwave Other (specify)

Specify Fuel Type Natural gas Natural gas Natural gas Electric Electric Electric Bottle gas Bottle gas Bottle gas Oil Oil Heat pump

Provided by

Paid by

O = Owner T = Tenant

Central A/C

Window Unit A/C

230 John Wesley Dobbs Ave NE

Previous editions are obsolete

Atlanta, Georgia 30303-2421

Office: 404-892-4700

Page 1 of 2

Fax: 404-685-4896

AHA Form 002 (December 2008) Replaces form HUD-52517 (06/2003) ref. Handbook 7420.8

Property Owner's Required Documents and Certifications

The property owner must provide a copy of: Deed Most recent Mortgage Statement (if not yet available, a copy of the Promissory Note) Certificate / Proof of current Property Insurance Management Agreement (if applicable) Lead-Based Paint Disclosure Notice (if applicable) 1. Check one of the following: Lead-based paint disclosure requirements do not apply because this property was built on or after January 1, 1978. The unit, common areas servicing the unit, and exterior painted surfaces associated with such unit or common areas have been found to be lead-based paint-free by a lead-based paint inspector certified under the Federal certification program or under a federally accredited State certification program. A completed statement is attached, containing disclosure of known information on lead-based paint and/or lead-based paint hazards in the unit, common areas or exterior painted surfaces, including a statement that the owner has provided the lead hazard information pamphlet to the family. Please complete and submit AHA Form 034 - "Lead-Based Paint Disclosure Notice". 2. The program regulation requires the Housing Authority of the City of Atlanta, Georgia (AHA), to certify that the rent charged to the Housing Choice voucher participant is not more than the rent charged for other unassisted comparable units. Owners of properties with more than 4 units must complete the following section for most recently leased comparable unassisted units within the premises.

Address and Unit Number (1) Date Rented Rental Amount



3. The owner (including a principal or other interested party) is not the parent, child, grandparent, grandchild, sister or brother of any member of the family, unless AHA has determined (and has notified the owner and the family of such determination) that approving leasing of the unit, notwithstanding such relationship, would provide reasonable accommodation for a family member who is a person with disabilities. 4. AHA has not screened the family's behavior or suitability for tenancy. Such screening is the owner's own responsibility. 5. Please note that only a single RTA may be submitted for processing at one time. 6. AHA will arrange for inspection of the unit and will notify the owner and family as to whether or not the unit will be approved. 7. The owner's lease must include word-for-word all provisions of the HUD tenancy addendum (HAP Contract Part C).

Property Owner and Participant Head of Household Signatures

Print or Type Name of Owner/Owner Representative (*see note) Print or Type Name of Head of Houseshold

Signature of Owner/Owner Representative

Signature of Head of Household

Street Address

Present Street Address of Family



Zip Code



Zip Code

Telephone Number

Mobile Telephone Number Date (mm/dd/yyyy)

Telephone Number

Mobile Telephone Number

Email Address

Email Address

Date (mm/dd/yyyy)

*Note: If payee is different from property owner, please provide payee information below: Name/Company Name Address City

230 John Wesley Dobbs Ave NE

Previous editions are obsolete

Phone Number Mobile Phone Number State Zip Email

Office: 404-892-4700

Page 2 of 2

Atlanta, Georgia 30303-2421

Fax: 404-685-4896

AHA Form 002 (December 2008) Replaces form HUD-52517 (06/2003) ref. Handbook 7420.8


2 pages

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