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<br />Inspection Form <br />Housing Choice Voucher Program <br /> <br />U.S. Department of Housing <br />and Urban Development <br />Office of Public and Indian Housing <br /> <br />OMB Approval No. 2577-0169 <br />(expo 9/3012002) <br /> <br />Public reporting burden for this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, <br />searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information, This agency may <br />not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMS control numbeL <br />This collection of information is authorized under Section a of the U.S. Housing Act of 1937 (42 U.S.C. 14371). The information is used to determine if <br />a unit meets the housing Quality standards of the section 8 rental assistance program. <br />PHA Tenant In Number Date of Request (mmfdd/yyyy) <br /> <br /> <br />Inspector <br /> <br />Neighborhood/Census Tract <br /> <br />A. General Information <br />Street Address of Inspected Unit <br /> <br />City <br /> <br />l~unty <br /> <br />Name of Family <br /> <br />Current Street Address of Family <br /> <br />City <br /> <br />Number of Children in Family Under 6 <br /> <br />Name of Owner or Agent Authorized to Lease Unit Inspected <br /> <br />Address of Owner or Agent <br /> <br />S. Summary Decision on the Unit <br />(to be completed after the form has been filled in) <br /> <br />Housing QuaUty Standard Pass or Fail <br />o 1. Fail If there are any checks under the column headed "Fail" the unit <br />fails the minimum housing quality standards. Discuss with the owner the <br />repairs noted that would be necessary to bring the unit up to the standard. <br />o 2. Inconclusive If there are no checks under the column headed "Fail" <br />and there are checks under the column headed "Inconclusive," obtain addi. <br />tional information necessary for a decision (question owner or tenant as <br />indicated in the item instructions given in this checklist). Once additional <br />information is obtained, change the rating for the item and record the date of <br />verification at the far right of the form. <br /> <br />o 3. Pass If neither (1) nor (2) above is checked, the unit passes the <br />minimum housing QuaJity standards. Any additional conditions described in the <br />right hand column of the form should serve to (a) establish the precondition <br />of the unit, (b) indicate possible additional areas to negotiate with the owner, <br />(c) aid in assessing the reasonableness of the rent of the unit, and (d) aid the <br />tenant in deciding among possible units to be rented. The tenantis responsible <br />for deciding whether he or she finds these conditions acceptable. <br /> <br />C--- -l UnltSize: Count the number of bedrooms for purposes of the FMR <br />or Payment Standard. Record in the box provided. <br /> <br />L ~ Year Constructed: Enter from LlOe 5 of the Request <br />for Tenancy Approval form. Record in the box provided. <br /> <br />[ ~ Number of Sleeping Rooms: Count the number of rooms which <br />could be used for sleeping, as identified on the checklist. Record in the box <br />provided. <br /> <br />Date last Inspection (mmlddJyyyy) Dale of Inspection (mmldd/yyyy) <br /> <br />Type of Inspection Project Number <br />o Initial 0 Special 0 Reinspection <br /> <br />I Stale [ Zip <br /> <br />Current Telephone offamfly <br /> <br />Housing Type (check as appropriate) <br />o Singla Family Detachad <br />o Duplex or Two Family <br />o Row House or Town House <br />o <br /> <br />D <br />D <br />D Congregata <br />D <br />D <br />o <br />D <br />D Olhar:(Specily) <br /> <br />Low Rise: 3,4 Stories, Including <br />Garden Apartment <br />High Rise; 5 or More Stories <br /> <br />Manufactured Home <br /> <br />Cooperative <br /> <br />Independent Group Residence <br /> <br />Single Room Occupancy <br />Shared Housing <br /> <br />C. How to Fill Out Thts Ch&cktlst <br />Complete the checklist on the unit to be occupied (or currently occupied) by the <br />tenant. Proceeed through the inspection as follows: <br />Area Checklist Category <br />room by room 1_ Living Room <br />2. Kitchen <br />3. Bathroom <br />4. All Other Rooms Used for Living <br />5. All Secondary Rooms Not Used for Living <br />basement or utility room 6. Heating & Plumbing <br />outside 7. Building Exterior <br />overall 8. General Health & Safety <br />Each part of the checklist will be accompanied by an explanation of the item <br />to be inspected. <br />Important: For each item numbered on the checklist, check one box only <br />{e.g.. check one box only for item 1.4 "Security,~in the Living Room.) <br />In the space to the right of the description of the item, if the decision on the item <br />is: "FaW write what repairs are necessary; If "InconchJsive~ write in details. <br />Also, if MPa$sM but there are some conditions present that need to be brought <br />to the attention of the owner or the tenant, write these in the space to the right. <br />If it is an annual inspection, record to the right of the form any repairs made <br />since the last inspection. If possible, record reason for repair (e.g., ordinary <br />maintenance, tenant damage). <br />If it is a complaint inspection, fill out only those checklist items for which <br />complaint is lodged. Determine, if possible, tenant or owner cause. <br />Once the checklist has been completed, return to Part B (Summary Decision <br />on the Unit). <br /> <br />Previous editions are obsolete <br /> <br />form HUD.525BO--A (9//2000) <br />ref Handbook 7420.8 <br /> <br />Page 1 of 20 Attachment No. 6 <br />