HUD Utility Schedule Model (HUSM) + LIHTC and/or HOME Funds Questionnaire

Today's Date(Required)

Name of Housing Authority(Required)

Name of Contact(Required)

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Extension

Email(Required)

Check all that apply

Single Family House

Single Family Attached

Lowrise Apartment (2-4 Units)

Larger Apartment Buildings (5+ units)

Manufactured/Mobile Homes

If your tenants are charged a monthly fee for renting/using any of the following additional utilities, specify how much they are charged monthly.

Trash

Range/Microwave

Refrigerator

Other (List)

Utility Companies

Enter all available utility providers within the County.

Electric Company

Gas Company

Water Company

Propane Company

Fuel Oil Company

Sewer Company

Trash Company

Other

Attestation*(Required)

I attest that the self-reported information in this questionnaire is complete and accurate. Errors and/or omissions may result in an inaccurate report and a correction fee of $150.

Signature(Required)

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Name

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