State of California - Business, Transportation and Housing Agency

STATE OF CALIFORNIA - BUSINESS, TRANSPORTATION AND HOUSING AGENCY EDMUND G. BROWN JR., Governor

DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT

DIVISION OF FINANCIAL ASSISTANCE

Rental Housing Development Section

2020 W. El Camino Avenue, Suite 400, 95833

P. O. Box 952054

Sacramento, CA 94252-2054

(916) 263-2771 / FAX (916) 263-2763

www.hcd.ca.gov

DETERMINATION OF UTILITY ALLOWANCE

Multifamily Housing Program

Project Name: MHP Loan No.:

I. UTILITY COMBINATION

1. Air Conditioning: Yes No

2. All Electric: Yes No (If yes, skip #I.3 and go to section II)

3. Combination:

Space Heating Cooking Water Heating

Natural Gas Natural Gas Natural Gas

Bottle Gas Bottle Gas Bottle Gas

Electric Electric Electric

Other (Detail)______Other (Detail)______Other (Detail) ______

II. EQUIPMENT and SERVICES PAID BY OWNER

(check items included in rent and not paid by the Tenant)

Equipment: Services:

Gas Elect. Oil

Range and Oven Carpet Heat…………………..

Microwave Oven Drapes Hot Water…………….

Refrigerator Swimming Pool Cooking ……………...

Laundry Facilities Air Conditioning Equip. Air Conditioning ……..

In Common Area Trash Compactor Lights, etc., in Units

In Living Area Disposal Cold Water Parking

L.U. Hookup Only Other (Detail) ______Other (Detail)______

______

III. UTILITIES and SERVICES PAID BY TENANT

(check items NOT included in rent and paid directly by the Tenant)

Electricity Heating Gas

Repairs Water Trash

Sewer Other

I certify that the above information is true and correct to the best of my knowledge, and that updated information will be submitted in the event changes occur.

By: ______

Name: ______

Title: ______

Date: ______