Wllkes.8grre, PA 18702 T€l 570-821-Sf4 rax 57G.8X3-7830
TDD; 570-829 -5634
Please remember when you turn in your application to also give us:
1. Copies of Government issuedlvalld ldenUfication for AII adults over the age of 18. **State Benefit cards even with photo (ie. .
New York Benefit {ards} are NOT 2. Copies of Birth Cerrificates for EVERyONE that will be
living ln unit. 3, Copies of Social Security Cards for EVERYONE that will be
livlng ln unlt. 4. ASSESISfi$OF APPTICATION MUST BE COMPLETED, DO
NOT LEAVE ANYSECflON BLANK {use none or n/a}.
Failure to give the information above wlll make your application INCOMPLETE & it Wttt NOf be processed until allrequired information is received.
Thank you, Management
IFYOU A.RE DISABLED OR HAVE DIFFICULTY COMPLETING THIS APPLICATION, PLEASE ADYISE US OF YOUR NEEDS NOWORCALL US TO SCHEDULE ASSISTANCE.
APPROPRIATE ASSISTANGE WLL BE PROVIDED IN A CONFIDENTIAL I'ANNER AI.ID SETTING
Please answe. all queshons includino 'N/A' for questions that are not applicable.
All adult household memberc must present a Drivers License or Picttre l.D and proof of Sociaj Secq.ity number o. explanation fornl,t having a So.iai Seclrity numbe,
504 NON-DISCRIMJNATIO}I NOTICE
h in
lf you have a visual, hearing or physical impaiment and need assistance with this "Notice", our porsonrel wili piovide or-arrange for appropriate assistance. ro^ schedule aagistrnce, prease cdr thg apartnrsnt community offi€e vveekdayg berwsen nre hours of If-o*:L,:1110!:y:-1:++I+rrl_;-..:. fti= imlu ,i,t
"ii-ippei ror ore rearns impaiEd.
I nBFercre, ptease ca the numbeG below, It epplicable:
RELAY: ftnrj r-aoo-zss-zsa9 (eoice) 140&73+2988 or d7t1.
l'his assbtance is provided to insure equal access in a sonfidential manner anat sefri.g- l{ ACCORDANCE WITH SECT1O .504 of tfte Rehabilitation Act of 1973 . Sherman } ,partmentE, hereby notifies the general public that
No qr,.rr:i:ed indivrdua. wti a olssb,. i) snalt, sotetv on lhe baStS of Oisaoil[y, De erC.JOed tom parbopet,on t1 cecFn'tu berents of. or olhe.w,sE be sr.F,ecleC ro olscrirninarror ,^o-ir"" i**"ify ,rs,sted prografi or ac{rv,ieadrr'l rlered b/ th.< ho!s,no coT.nun iy.
We n l, t'lvde emolovnert ooooflJn,l,es, treneftis, accesg ro holstng a.ld o,ie. aopropiate sefttLes ,. a inartne-fet wil: 10: drre€t y or througn conlEcruator otier a,,ancement s;b'i".J, iJr,,r_""0",n0ruar",, *ith a drsarlrtv tod'scnminal,or sotely on 6e basrs of disab,lrty.and,
we v'1ll not perticipate rr aov mnlracldar oa other rcJationship dtat has ihe efect of subr,ecting a qualified individualwtn a drssb.lit, to clisc,tnrn;t'on solet/ on the bas,s of Orsaoitriy
is the intention of Manaqement to iake roasonatle, afirmative steps io insease access and opportunities for drsableddiv'iduals in all programs, services and admrnistrafive operatons_'- -
'e haie designated_Martha Simmons , to s€rve as the S0.4 Coordinetor
l/vl,e have read and undorstand fte flN l{o|r.Dlrg]irrinaGon Notice. All adujts must initialon the line eroyided Please lnitial:
Appli.ation For Resideocy
Apphcation For Residency
T|1/E
NOTICE TO APPLICANT
PLEASE COMPLE IE THIS A,PPLICATIO\ AND RETUtu\ TO IBE RESIDENT IV'INAGER AT fHE PROJDCT OFFICE. AIPLJCATIONS AFX PLACFD ]ft_ ORDER OF DATE AND TIIV1E RTCEIVED, AN APPLICANT MAY BE INTERVIEWED ONLY N,fTER TIIE MANACER RICEIVES THIS APPLICATION CO]UPLETED IN FLTLL,
TIIIS APPLICATION AUTOMITICALLy EX?IRES AFTER SrX {6, I|fONTHS tn{LESS YOU COME tNlO rHE OFFTCE TO RENEW.
GENERAL INFORMATION
PREVIOUS ADDRESSi
Ifyou were 62 ycals ofage as ofJaouary I l, 2010 and do [ot have a SSN, and were recciYing HUD rental assistance at anoiher location on January 31, 2010, yon could quali& for an exception from disclosing and providjng verificarion ofa SSN.
FAMILY HOUSEHOLD COMPOSITION
LJST ALL PERSONS WHO WLL LIVE IN THE APARTIVENT, LIST HEAD OF HOUSEHOLD FIRST:
BEDROOM sIZe REQUESTED: ONE EcDROOII
Four Bedroom
AHREE BEDROOi,,I
INCOME USI,4LL SOL'RCFS OF iNCOM€ NS REQUESIED BELAW FOR ALL HOUSEHALD MEMBERS:
NAME RELATTANSTTII DATE OF PILICE OF AIXTIT soctAl sEc No.
J
6
d
OFINCOME N'ONTHLY
SOARCE 5
INCOME (CONTINUED)
TOTAL CROSS ANNUAL INCOME {Base this on the monthly anounts listed above and nuhipty x 12)
Da you articipate a y Lhanger in hk tuane h the Eat I 2 nohths?
4SSETS
CERTIFIC,ITE Of DLPOS]T
C ERT i-F 1C A T E O F D E ? OS IT
A''COUNT IA NAME AAlJNCE
SAYI\GS SONDS
ACCOUNT ]\iO. F.4CE YALUE
LIFE NSUR iCE POUCY
Peal Ptop.rty: Do Jo, own ao; land ot buil.lrgt? ir'YEs ir o(P,.;-to,
Yolqe oa Most R.ceni'td 8i1l S
llottsoee oror$n2atlnls l,@N galoace Dae S
J .t
RENTAL APPLICATION (HU D) PACE J
tl@-e you ar ay olthe tisledJbnib,de be6 'ol*dkpcsed
ol any kn{i o,'tuldt"gs in rha,r.t tto Q)reaB? }'0i --,&_-__ IF YES, Trpe of Prcpefiy'
-
H aw y ot d i'p $. d ol a,'t ;t., * " *' *7EiiiGf, 6G *" t^-fr 7Z*Ai
(E\anple: Oiven @at nanet ta rctnliw, s.t tp iiev@dble tr4t a.cat\t .) 1F YES, D.tcribe lss.t:
A,hount Dispoted: S _ Do lou hove an! other as'et" air ris"a oifrTfiiifiEfiiinaiViopery;z
/f lEl ,!rr
MEDIC4U CEILDC/4RE/ IIANDICAP ASSISTANCE EXPENSES
L M.dical Cosls Conpkte this parl ONI.Y if ,lead ot Spoura it 62 o, ol.l.r, DlxaUcd or Hantlitatpe.t lfso. irclrde on othtsfo. Alllanily n e,nb.a
Yrs _-- .\b
M.di? c Preriuhs:
Medical lhss?ahce Ca\"roge: liahe o! h1:tvoh.e Cdnpa,y: Addrert Moithly Pte|li'th Cost S
;NTC|P,{TED Medi.au Dtua/ PrctctiptbD Costt NOT Cot*ed b/ lt6annc. lrOR Reinbwi.d: )lonthl! Ahoust I Medial Eilb bt Otktun
"E Casts you Arc Yaki"s !$ofthly Paywnts For:
Baianc. DE: s
-
t;o
frcjectedCons NOTCo&''rd bt l6et ceitARrri br\edfor h.Nexl lz u8ths: I At! Othet !,,lEdot E pe,s.s LLa Tto. 4, 4ao0t
2. Childcare Cosa Co,npLr. ONLY fo..[ild].n 12 & Young.r.
)iohe(s) ol chitdrcn Caed Fo/: Age: _ AC, _ Age
--AA.: _ treetb Co fat Childcart D,e ta E ploynent tvceVy Co$lN Child@.e Due to Edu.niot
J. II an d ic op A s sistan c e E xp e w e s List Typ. of E peAses, Weekly Ahorni Paid td whotu:
H&e foa erer beet evictedf/on othet hoasing? yes _ No Hot dirl tou t@t aboul tha Ho,,t,re? _ _ _ Will you tdkz ah lryrtrleit \rheh on, i.t a:,ailable? }?i
-.--_ No
PROGB,4M INFORIUTIO!\
*erou d;sph.ed? Y.r lF YES, Dhpla.aden: ti?anq,? tF YFS. By Whotn? _htot cuncdtunit coadehn?d2 Yet- lio
Do latu h@e du" spzctut,eedribt housinq? f.!_ Xr_ lF )'LS. d*oib. trLet & ert nt ofruedt.
Arc you d l'etq ai? f4- Na
-W
-
Ib
- Are ryu ot ohy n.nb.t ofro , hotlrehold enca$d il the dte t ileeal,.se ofa.ohtrclbd substa.Ea? /.r-.t;_ HaE you or any deabet ofyout ha6.hod zwr been co,victEd of iq.eol m@lactv., sal., or disnibution of d coaiolled \ututa,cz? Y3 \b H@eyou ot.iy nedb.roha* hoaehotd der b"eh ch@BeaconicEd ola hisdeneqa@? ver- *"o- Hatz ,ou or sa! nchbe, oflou, ho$ahoA wet b.en chzry.d/cawi.ted 01 a l.!oiy? ves
-
.\'o IF YES. NqDre & /d&zss: _
Ho|e youer bear aict dfron' Public Hoalue ot any othet FederalHdsi"g Progruh? Yes
-!io.
gieft! desctibe yow r.asoas fot a?pi'iag.
RE FE RE NC E I N FO RM.1T I ON
RENTAL APPLTCATTON (HU D) PAGE 4
Cuteat Landlord (From:
Prior Londlotd Frcm. To:
1&lress
ln Case of Emergency, Notify: .\'ar e_ Add/ess
OTHE R fr.E QUTRED IN F O RMATION
Lifetime Registrqtion Requircment urrdet a Sane Su Offender Regis''8tiot, Ptogram: Is ont p.rton eho .iiu liye in the opdn.nr tubject to a llfeti.nt tuElstra oh rcqki,em.nt unds a State Sd Oflendu Rqisoatioh Prog,a'n? Y:,]J- No Ifthe znt,R ls r?s, pleas. lin lhe hone oI the houtetokl h.abet did rh. stote(s) ehere registrulio, is ftquirell:
List lhe dme ofeach perion N,ho will li|e i4 the apaflmenl ond the slate(s) eheru thal pe$on b knowa to have resided.
L6t N@ Fahr Nb. ,-l- Lln .och stdt id *hi.h thi. p6on is knotn to ho* rzslden Y.L ru dhbr.\'iat.- l.a-. I-a. NJ. Nv- rY.
-
Plate No.- Tvne lrehicle Iear/ Make Color Liceise Plate No.
PETS: Do you own any peu? Yes
-
No
FA M ] I- Y N' F- M B F, R N,I IlI E ST/TE NEQUINNA
PEGTS|PAIION F.1 T'I' I. Y N4 EM B E R N.l ME SIATE BEOUITING
IEGISTRATION
CERTIFICANON
L'Wa kteby c*nfy *ar I4'e doirill not naintaik d tepeffirz sbrtdted rental unit in anothet locatioL I"*e lunht cei'$, rhat thtr till b. tfly/ott perna ent resident . fqe uderrta"d l/re h$t pd, a se.wity dipot lq ihis apa4rett priot to ocap.rct t'We ud.rsted $or ,o eliSibilir-Jot h$ihg wil! be baten o" U.S. Dapotl'nent of HUD -t .o@offapanct lifrils dnd by The Aryen ConpoAies ralec an o ite,ia l/tle ce,tLb that all inlonlotio, in thc npplication E ts. to the Lzt ofny/our kio*ledge did la'e d2$tdd thotiake statereds ot inlorhoti@ arc ptllishoble 1+ te. andw leod ,o c@te ntio, ofthts application or tenninanon of tennE) a/@ a.dpow].
S]GNATARE:
AWEOXIZITION
I/We dn h*b) arthorize Thz Asp.n Conpaaiu. and iLt stdl ot aarhoti2ed Ep@en,ati:,, to .o$act ary apEies, ofrc.s, graryt ot orq@izatioN ta
obtdtu axd wif! aty Wolhdtioh ar not.tiah nhi2h are da.n€d rccessd))t to cadpl.te n,y/ot/ applicalo, fo, hawrry ih proetults odni Xtend,MaaAed b'Thz Aspe, Co'n?aniet.
SIGNATUAE:
,tPdLsf.l
DATED:
PLEASE PRESENT YOUR DXIYEXS LICENSE AND SOCUL SECURITY CARD WHEN TUBNINC INAPPLIC.4TION
'Tit!€ i8. Eedion l0OI olthe U.S- Code sutes that a perloo is Builtv oia fclony for knowingly and wiliingly aakiflg fahe or irrudulent gtar.mcDts to any depomrcnl ofrho Unied Stales Covemmeol HUD and anJ, o*nei (or say employee 6iHUD or the owncr) may be subjeq ro penallies for unauthorjzed disclosures or improper Lise of informatioo .ollecLd ardred on thc consent torm. Use ofthe iniormation collect€d based oB this verificatior form ls resFi.ted to the purposes cited above- Any person tr,ho l.-no*inBly or $illingly requcsls. obtains or discloses any informalion Dnder falsc prerenses conoeming an applicaot or palticipaol I1]ay be sut'jcct to a misdemeanor aDd tined not mor€ than S5,000. Any appl;cant or participanl afi.cted by n€gligent disclosure of infornation fiay bring civil nction for dama8es, and seek olh€r reliet a! may hc sppropriare. egainst the oill.er or employ.e oIHUD or thc o\f,net .espons ible fw the unauthorjzed disclosure or improperuse. Pcnallv proyisions lor misuring fte social siclrir-\ number are conraised jn the rrSrcial Srcurity Acl a! 208 (a) (6), (7) and (8). Violation of rh.se prolisions a.c eiEd as liolations of4: u.s.C. a08 (a) (6), (?) and (E).r'
Owner do€8 not discriminate on the basia of handicapped status ln the admisslon or accesa to, or treatment, or employment in, lts federally asgisted programs and activitie6.
O1\\ER'S AGE\TA,,!ANACER DAlE
Revised 06/2016 @
Suppl€menMl ard Optiona) Conlaet lnformacon ffi HuD-Assisted Housing Applicants
SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSTNG This form is to be proMded to each applicant for federally assisted housi,rg
Instructions; OptioDal Cotrtrct PersoB or Otgroi:rtior: You have the riShr by la* to includc as pan ofyour application for housing, the name, address, lelephone number, and otler relevant information ofa family rEemb€r, &iend, or social, health, adyocacy, or oth€r organiz.dior. Tlis coEtact information is for the purpose of idendrying a person or organization that may be able to help in resolving any issues that may arise durirg your t€nancy or to .ssist in providing any special care or s€rvices you may requirc. You may opdate, r€move' orchange t[e informatioD you provlde otr tbis form et lny time. You arenotlequired to providethis contrct informaiion, boi ifyou choose o do so, pleale includr tle rclevan! information on this form.
n Check this box lfyou choose not to provide the .onract inlormation.
-{pplicant Nsme:
Mailing Address:
NaII)e ofAdditional Contact P€rso, or Organiz2tiotr:
Telephorc No: Cell Phone i"o: 1,-Mail Addr.ss (if appli(.ble)l
Relstionship to Applicant:
6m.rgeocy Unabl€ to contact ),ou Termination of renbl assistance
Eviction &om urit I-aie pa)ment of rent
Assist *ith Recertificadon Process Change in lease lerms
Change in house rules
Odrer:
Coonitmenl . f Holsitrg Aurbority o. Owncr: Ifyou arc alprolcd for bousing, this inlormadon eili bc k+t as pan ofyour r.qlrt 61.. If isrues aris€ durirg you. tcmncy or ifyou rcqoire aJly se^_iccs or spccia.l care. wc nay conhcr &. pexsoa o. orgarjzarion you lis.cd to alsisr in rcsoiving O. is$ues or an prDvidioa e-. s.rvic€s o! sp.cial l:e rc ),ou.
Co! fid cDii,lit! St t.m.nr: Tt. infomadon prcvidrd on this form is confdc ial ardvill Dorbcdjsrlosco ro a.1)one excepl ai pcrmjncd b:' rhe appliclrt or applicabl. l6v.
L.g.l Notifrrtio.: Section 644 old'. Houshg and Communiry- Dw-€lopm.nt Acl ofl992 (Publi. La\' 102-5J0. approved Oc.ob.r 28, 1992) requins eacb appli.u! for tudd?llv assis..d housins 10 b. ofe..d orc oprion ofprolidirg irfoftatioo r.3tlIdina an ddirional conlacr p$so! or oratrizatioo. gy acccpting th. arpllcant's appli.aliotu the housing providc! ae.ces !o conTply wi$ rhc Don-discrim;rsiion and equai olportunirl !.quir.mmts of24 CFR sedion 5.105. includlng thc proiibitiors on dis.tjminado. in adrnissioD !o or panicipation in fcde.rlly assis.cd housing !rD!irr$ on lhc brsi. 6fra.q c'Ilrr, rcligioo, national origin, sex, disabilir), ard fihilial srat,rs nder iie Fajr HousiBg AcL .nd th€ prohibirion on age discnmination undcr fir Asc DisgiDinadon Act of l97J
Sig tureof^pplic!trt D.te
peurc n!..nng t{en E 5ird.d n I t drds Fr dT@E, mctulin! llc iid fs Bi*rE idud6. s.}jns d$il: &u br&i 8.!t.s! ad dinbiine rhs dr! n&d.4 rr! cmptih6 -CEridirg t.oldi ofintwdid.ShiLn6raofrn.t66in8.idCJM@!O*ldro.nt^doaL,2111U,S(lis04)i'p!'rdoaIILD.o5li8riio,ror.{r[.urirgp.!id.r
.ddra r.Ldbe nuribd,.rd orhd 'cl@r i,,f6Eho of . frr4_ ,Mbi, ti.nd. e Fs 6ei.kinn. sj,r, har*,,rs*v, d rmn, o'luiajoD Th. orjrui* of F$id E $ci,
nsolriis by r.@! i!u6 dirng dlrins rr. @Dry df s6i' &6t liii 3loddhnrr rrrliuris i.folBis i3ro bc tujDrted by lc l,ouri.a E&rds &d $diDi.cd d r&iid.tuid infmraq ProYidiost i.f@ion is n'si. b rb.6o.dio.s ol,1. t{lJD 4ss.d-:lturs iro!* 6d B hluEy t, opeo'rr 9truq *q**aa -,a p.o€rs md.'@Fmd.mrots rhr pr6d frad sr:! ad Fi:l|@a.o.d, ,r rcd.nnr. *i$ $L P.FBdl Rai6rn {d, &.g.,r_..@y nd sdd or!}r,lg. ad r 9.6f, ! Nr aqurld b rgdndq r oildtM oaiofom.li4, @l6e$. coll<ion drpla$, 6dily Llrd O|,,G .oE@l i(ht6.
Frivt! Sbuffi l'ubli Lr 102-5t0, turh'ia $. Dcrdrhr oft tuing .in U6$ D.tEbpHr (H!rD) b 6rl.d .I ln. n'f.mdi6 isc.lr rk S6nr S&siry Nutr aSSN I qni.n wdi b.
uEd ir HUD e Fdd JisLBeM .Lh fre 6rd!l,I i.lioir Em llL'L ,006 (Ctror)
U.S. Departm€nt of Houslng and Urban Developmenl
Document for Applicant's/Tenantls Consent to the Release Of I nforrnation
Thl! Package co talns th€ lollor'r{flg documelt!:
l.HUO-9887rA F.d Shoot de8criblng th€ oocessrry vorlllcatlons
2.Form HUD.9687 {to b? slgn.d by th. Appllcrnt or Ten.nt}
i.Form HUD9887"A lto be slgned by the Applic.ntor Tsnent rnd Houslng Ow$€t)
4.Rsl,wad Yerlflcatlo$ (to b! slgned by t$o Apptlctnt or Tentnt)
Each household tnrst tccciYe a copy oflhc9887/A Facl sheot, fo.m HUD"9887, a,d turm I{tlD'9887-A'
Atlechdsnt to rormt HUD_i807 a i887'4102/20071
I
Verlfication of lntormation Provldod by App,icanls and Tenants of Asslstod Hausing
t{hat Vorlflcatlon lnyolveB
To recrilvs hrusino assjslan@ applconts rnd lenantE lvho Er€ et t6a5t 18 y6a.s ot ags anc oach famlly hcad, st)ouse, or co h6ad rogardtoss ct ags .nust provld€ ltu ol[r€r or nra$ggmsnl ag6n1{O/A) sr publtc houstng s!€ncy (P,lA) wllr .enain inlornation specut€d bf lh€ U.S D€partnsni of Housing snd Uban O€velopm6.rl (HtJD).
Ts make sur€ tl.€l lh€ B€6l6lanco ls ussd pmpodr, Fqdqral aws aequire lhat lho informallor you provlda b€ vsnfsd. Ihls infonTalion l5 w'ifiod in 16!
1. HUD. O/As, end PHAS may v6diy tho iniomaton you provrdo by ch€ckinq v"4ih lhe rocordE k6pt Oy c€.tain p!b]. !€6nc{6s (0.g., S6cal Ss.urily AdmlnlslElion (SSAI State s€sncy thar ko€ps wa93 snd irnemploynr€nl conponssllon clalrn ln{ormstloo. ad the Deiadme(l ot1'aallh and H{nnan S€rulces tHr{Si Nnllonst lli.odory of trls,,r qift)!; ii.,lnNl-i) datsi,nsq ll|at lrorcn $rit€,.ow htres.6nd unemploymeflt co$psnEallon). HUD Jonly) may verii/ info.ma on c!v6r6d ln yolr lar reilrfls kom lho Ll S. ht€msl R6vonu6 S€rub€ l RS). Y.! give yo!' coNenl to th€ rskrs!' ot thls intormaUoa by slgalnq rdrln HU? ?8U7" Only hUD, O/ J.. and PhAr crn r€c€lvs i lolmalion aulhorized by lhi6 lonn.
2. Iha O/A musl v6.ity th6 inlomaton rhai t6 lead to d€isming your silgib ri(y and th3 s lovt* ol renl tou pay. You glv€ yolr co^s€n( b lhe rukrarto ol lhls ln,ormaliofl by Elgring the lom HUL\'0887, th€ rofin rlUD-9887-A, ard th€ lnClvldual vodficrtlon and oonsont torms llral al]l1yloyuu ledsral r1trvn limlt lhe klndR ril lfllonn.rb,r the O/A car r.,ar!6 ahnul you. Tho rmouni ot rrrconra yolr rocfivs h..r!s tc dBlermlne lhs amount ot rant you wl[ pay. rh€ O/A wlllw.lfy aU ol ths solrc.is ol incamB lhal you r6pod ThBr€ Brc cedaln Ellownocas thal reduo€ lhe lncoma ussd ln detormlnin8 knanlrsnls, Exsnrrildi Mrs. At1de,r.n is 62 rjars a&1. H€r.gs quilitie,j rl9l lor a
'-l.!iBl alorri,n.. Her arrlul lr!L.{)n'e wlll b€ adluslo:J rdrrls8 ol thig allowen.r 8sc€uso Mrs. AndarEon's m6. c6l expeasos will he,p delomill€ lhE amorni ofrcnlsi€ pays,lh6 O/A ls requlr€d lc v6ri{y any fil€dicaIexo€n8ss lhat 6ho r€oorls_
Ex.mpls: Mr. Harrls doos ,rd qu.ll.1 to. lho medlc€l allow€ncd bet!,is€ ho ls not ai l6a$t 62 y€Br6 cl sg€ and h€ is no{ hand capged or dsablsd. B6c€us€ h€ ls.]ol6liglbl6 for (hB medlcal ailowanG, lh6 anoun( st ht6 rncdlcrl 6x$onsoE dN not 6i€.tg€ ihe amoufi ol .erl he pa!6. Ther€farc, th€ OIA c6nnol ask Mr Hanrs snrth{ng abou! hls msdicsl 6r(p€ns€s snd caflnot yed{y wilh a ihkd le.ty 6houl.ny nt6.li.rl exp.nr63 ho has.
Custom€r Prote.llons
loiorrnEllod r€c€l!€C by HUO ls p,olded by thB Feioral P,lvicy Acl lnlormation r€c€iv€d by lt6 OIA or lho PilA 16 sublloi to Slrlo rrlvacy i:r,i! E iflryoos ol lrlrD, rho O1A, a.d lhn FllA nr6 n,,hl/tr.i ro
t)dr, ll!r l.i utln!] thoso,I.sent ls.ls i,nproporly Yoir do nol fnvir io .,!n llle fcrm ilili1.!83.I lrre lorft lluD'988a-l\. or !r!E hdivi{ual vei'!t.;aiqr rc *(.'11 lGrn'9 y/an ih.y irn glypn lo you nr ynrt c€rdlicstlon or r€.fnifiulion lfiterviaw. You may raks th€m hom€ wth yo:; lo rcad or io disouss w,th a Oird pa(y ofyou cloj:oe. Th6 O/A wlll liv,tr yo! anolh€r dat3 \ahen you cafl rslu.n la rrlgn lhose forms
lf you c€nnoi r8ad and/of slQ* a coflsonl loffr due to a dlsEbliity, lh6 OIA shall tr'sle a rsasD.al,r aai'rrmmodnllon in acrordenc6 with S6ctlon 504 ot th€ RohibitllaUon Acl ci 1973 Su.h ac.ommodatlons ,fi;i,klti,xte. h6ma ?sls a,tirn the appli.-irl's oi l€.lrnr disalr'liy inrhnl.: rirr/i,r. {'o,r .or$lrg t. llro olfico lr (}}rDlsl., ths lotrns. (1,.1
airrllairl ! liirrr.rrrl nNlIori-li.! !r'dttu pe6on lo ilita s' l,,1itnx l-.ol",oil lnd (or parsors hllh !,is! BI lflrrdlr'n.erl! rr,conrxol.li n$ r,ry n.lr,do prorldlryt thc kxnE lll l6rti strltll (Jr brarlie or llrrlidli!
Il irn flddl mcrni,or ot yorri lroosatLolil d!;a, Io Bnienuntir!.ifli,rist!,rcr., i! ,rlairl* Ir srgfl li.i {fini rll-Q-qrg7 o, lhe *niiv uil vdrlL./r!.rr Llns @ linE l\ft l)/ mby doi:*renr rlx: nl* ,: b l!r{} irnsar li{ iho d!lr} }riI llrc lnulit,l tr1r9I(J oliliii l'n nr.l8r srlrnhnn as soon ar r,!(srirl6
:ho C,A nrJ\l (,,{ iou. .r' ,r lr,l,d pnrty w}lldr yoo dios{6, ot tri} lirnlintF nrids rs a rl|lll ol !11!r lllA r.rllx-an(xls aulr.rund b/ v.rtr (1r| r, Ilrc O/A Lr,r lryo yrrl lrri oplorivrrlf 1o ..r'lo!l !ut,r {rJr,inci hr ac.drdln@ wi'|, llUil l,nr}lbnnl {3sc3 ile! 1 rtrwL!.,, :rr r^lorm,?rlon rcc,rlvod urkl8i th! fo
' HULI-t88t oi ,o.r1 tlu0'34$i/"A. lri.io,lrlo
O1A, or lhe FHA, filoy iniorm yo! oflhoee llndlngs.
O/An,!hrl lo€tr lorrnt ll{:r tr n rocall,)n lr\at gnsuros contdomlality Any rn!,,hrrec ')l llw OrA \{no trll$ li, [0op iansel irtorlii'liol t4nlidsntiar is .irLlrd io 1l|e €nl)(e ndnl ircvlslciri ol lhB Slth Pnvsr.y Ac1 and is lr,tjecr ao nrb(nmon1 actlons uy l[rD. Alsr, 8ny applrcn[ o. t6.dxl dt .l6d by nopllqsnr 4m.io.u,e or m!(;For u:ro ol nrf(rl{B(rn may bnrq clvll aclion lo, aa4)iQcs,3r:d slrl ollrrr r€li6i, a! may ir€ Hpp,oplat!, sgaiost lh!
,rUD.,o887/.'\ ioqr{rBs thq Cr/i l. ,i!* 4nrt! hous6l'!)rrl 3 ioit! ol tN{: r€cl 5ll.}rl, n^d iorlrs flu! 9t187. llull-la8r-A alon{, wilh loFrcp&lo l.rdl!,ldLral cnffiool torrrls. Thd packrqd yiru wlll roL'rivD will irrdudo th€ Iollofin! docum€nlsi
1 . HU E-9687/A Fcct Shoo(: Ds6€rtb6s ths reqdr€monl to v.r(y inlormatjon p.ovldld by lndlvidlak who nptly ior housho assist ria f|is Jrct sh€ol also drlcrlbes crni,ufiror orotoclions undsr lhe v6rlic.ti.n
2.Forlt' HIJD-0987] Allo$is lh6 r€loale of in{ormallon balwsen 9'r!ornrr,€nl6scncbs 3 farnr HUO,988i-Ar D€6cr1bo6 l1l9 ,€quircmon( ol thkd gany vsrlri.qtlsn alfig wiltr mnsulnor txshlclio,l3 ,:.ln.Jlvldotl lorlticrllo.r conaadli: Lksd lo loJlfy lh€ rdl€vsnt inlorrrullcn p,cvld(d hy apprll,.l$,/ronants to d6Lrnrns lt€t. €liglbillly snd
conr.q{..cer lo. t{ol9lgnlng th€ con!.ot Forms
lf yo,r aro an dprrlcact rnd ,n doniad ssslslnrF lor ihJE r€aso.r. th€ o/A must nollfy y6(r of lho rrrcn lo. yout ie,:1ion and 8i\,6 you en opporlunlly lo app€al lhe declston
li yc( ore a nlinrl afd yolr srEirilrum ls t6tmlnal6d Lr hls (o!son. lrs r)/A musl ldlow lho proc€du.s s.! oul lq lh€ 133s6. Thls irduics lns opporlr.hity lor you to mo€1$'{lh (he OiA.
Programs covorod:,y thls Fdct Sh.Et
R. ntal Asslstaocs ProCram (RAP)
Rent Suppl€rnenl Secllo.! I Housln€ A5si3lan.6 Payo|ents Programs (sdrnlnlst6red by the
Oma ol riousing)
:J6clldn ?021162 PAC
Sgclion 238
HOPE 2 Hom6 O,rnershlp ol MLrllfam ly Ur!t!
Itrs lo,nr lilr0-9887. the lornr hiUD.9ti87-4. nr lhr: krnr". (li nrry ,ilsull t y,!r a6.lslnr,xr
Notice and Consenl for the Releafo of lnformation to th€ U,S, Deparlment of Housing €nd Urban Dsvelopmenl (HUD) and lo an Owner and Management Agent (O1A), and to a Publlc Houslflg
O/i ru!!6stk{ ,.,east lnlum8lloo iorner shorld pio,rido nams end 6i,ii1tos$ ol tllo Ownor )
Tle Clcnp0intD C.ntrc Wa( 500l6nk W. Blr Blld i/4?
Ir'ncc[. NJ 0?666
PllA r3quo5lq$ rqldsxc c, lnlorftatlon {rfrvlr€r should rj!o!i!,r tho Juli r.(!,.,1d .,dd(,tst ollho PHr\ nri,lho L tle of tho dxrctq or it1l,r i,,itlr{rl.or . ,r tr$rt i6 no i'11?1 Owfi€r or PHI conlrscl odminlstrslor for lhls prolscl, merk an x ihrolgh thls efltkg box.)j
2lI NorthIronlsrioeLIlrrilburg Pe.nlrlvar,a lr!01
lio.matb ll oblihi li it lndrnco willr ltlry airollg.blo glalo lrfrecy lai!. Att r rt.(.irirE Ihe lillorrurtllrr coli.cil t,y ll+s ,\otict ol .{rn..ril, llUO, lns 0/r'\. end lh{ |}ilA niay hlot! t yor lllnt rrur irl,rlt ll{y lDrr cr lD!s,oI, istlslan€s li u,ried.rh rrfiJ nl:.$i. lo l,t vt'r{r.1d e,}ii ,l0ll!,r.q 9fte,
HUD, OlA. 6rkl PHA cawk)'rrr6n ouy ho tilbjerl kr nunnlttda ior u rulhorlro, dlcclosufss or lm!,wsr !!o:t ol lhs lt].lxt€ lnioirnalion li,d ls cinlinod lrr.dl on lhs @ni€rl foffi.
Wio LuEt Sl0ll ihn c6n(o,rt li6rrn: l:3rh n${nrnr d yolt lmuBahotl $'i$ ii n! trBl 1B Bdi:6 ol r,g{ ad ca.i {.!r'il} ixrsd, qrou.lo (, (+troad. lctFldlosi ,l n!*, mn-r,i strr tr r4nsr l l.tn\ d Urc inrilnl r..li!;.liorl a^il 31 ta(h ,s.rertil;qrliot Ardltl.,lrsl tlyrih'es nurl t. ot iired lrotrl rt\t arral munrno,n {riton ln.y loi., lrlB htx3lh1rid ur $na. nrofirll4r6 Dl trr! l$'.'n}lll,.l b€crfis l8 y€ere 6( als.
F€mo6s who Bpply tot or rocalw asslslanca und€r lhr tollowing programs ar9 mgrilrod !o clgn lhis conss$t lorml
Ronisl Asslslatc€ ProE[8m (MP)
S66lion I Houslng Alslslanc€ Paymenls Plogams (.dtrinls(orod by the
Ofllce of Houslng)
Secllex !02; SecL:-.! 20? s.d 81-r PP4C;Socl.n 202/16! P.a.c Sec!i..
221(dX3) Bslow Ms*61 lntar€st Rato
Sddlon 236
HoPE 2 Homgownorshlp o, Mullllsmlly Unlls
falxire ro {itrn C.xiriull Frrln: Yell teillio lo diflli ltri i,irr6l'lrl l'nn rrurt r6:i4 n, rll{| {irnt'! t, *s*rsisntt (, hmrin.llon ol ,5s:xlcil trot'sltl0 hoit rlilr,. ll an arl)l,asl 15 d6ftl.d e$tthri(6 L* lhlr.(&ion, ltn own6. nl'13r,ollow lhu nokt;rkn procsrrx*, in ilandbrol lilllD x tlev. 1 li 3 l.oa.l 15 risrsti 2e-<nttnce fJ 0ii5 r€tsr]ll lht, olrd r., rl,,,!l,tlilg ag.:nl rr['st ldllofl lhd paoc€dur€6 rcl oul ln lho leas€,
Conssfllt I conBent to r$ow HuO, tha OrA, or tfid PHA to aoquelt snd obtaln Income lnlormatlon arom tho fodetel and alrt! lgoncles ll6ted on ttu back ot thls form for the purposo ol vedfylng my ollglbillty end ievol ot banofltg undol HUD'3 .a6lstod hot tlng proBGmt.
Addilbnal Slgnalur€s, lf n€ed€d:
O,lrgr Fr,rny M!n{&.5 18 odlsvor
U,S, DoPsrtnrgEl of Houelng .nd Urhet Ecvdlopmsnl Offk€ of Holslng FedoGl Housing Com&b8ion€r
collsont on a datoyoo hrvo workod outwlth lh. figuclng owngtlmansgor,
Arlllorlty iia(lnn 217.1 lrr i;*nr.oll.hll]d .^ppropnnlioP Ad ol 2l'0.1 (1'ul l-. 101r'1$g)'thii lsw r{ I.Juid rt 42 Uij ()-0!l(J} -}ti, lnw Butho.lr.li lilltj lo drs{rrse lo llro t:}6rra,lm.nl ol llrnrsl,}q rfliJ Odnrtr {lovnlo,rrnr,{ {ilL,O) ldom*li,}r l,r lrt{ NUNII po,tion ol U}o 'l.uriliHr lild Coll&qllo,r gyrl,,:rn ol Rrn;!,Ll'.'nr $ I,tn{vJ6ni ol !d.it llo €unt oy,lnlnl$ i hc'r&r r]i l,,d,,".irual6 li,,iiii,!nlr!$ l,r t pciliir/l ixoarrenri 6od. $lkr ronxrlil ot l!'l;on l ldolrli8orn, to cofldud ,naly3o6 ol lho employnHrnl cnd ti"o.ne ryiorlku ot lharo iftilvlduob lnlormation m6y bri dascro.ld by llE S011116r,ofllUU kr. priva(€ owrcr, 3 men60o,ir(t.]l agonl, and a c.nlra<l adrnlnlsrslor in llre nd,ninlutrdtlon at rontal housln0 B6rlNle.rc€.
Serlion 1lO4 ol lll3 $lowarl 8. McKlnn€y H(,lnal6fi Aslhtarn! An16ndn13nls Ad o( 19u8, ai snlendsl ty lsclrn ao3 af ri16 Hovslns axd Commun'ly noldrerntld Ac! ot lSgZ and geclon 30Ol ol iho Omn.bu! tru(lol Recoturr,.r']lr A(l !r 'xvi lhls Lw rs {ound at 42 U.$C. Jr441rls l,w ,ort{lro( X\r lo ran a rols$rl to,m aultro't,-1n!r {1) lluo nrtl (ho PHn &r ,irqur.t wngo arxi rrlcnpby,rdnl .1}6rt-'olr5,11ion c{aiar h*rnllhlr lronr ilB :tile irco,r!, r si! $ilib l$ leFlri! ihal i.to{rl.tur, ll,ld i:} llu0, Ol^ {]fi 1i!. Ftl ,rrronal,l$ l.l drk,ni riflO olBlhltlly lo n:jrily !a1a.y and v7nt. !/rr rulidn nrrrnia.r Io U*r rpl'llqrnl6 (n prnk |ltlldr o$dltlllly nr l v61 ol r).,F,1I3. (3) t1l,ll rn ,srl1}!l .}rtrio hJ( r*lirm |lttrnrctre,r ,.q.r lho 1,"S.
9rrclnlJi4driiry&Jn,l.;{r..lio {s.sA)flnllhnU g lnro,fln,lteti},l1m$4M{:o{lllS)
Itsrrior.: l,r thr*,, tfu: ranrarr 1l, , ),r)* ^r. auitF,nilr! lllrfr.lla llt(a..
nrn)d r:rA, n.rd [u l)]1l\ ln mq!{r.l irrrr* kllonMr|on rroc} lr{, rjovlrr,r nnl
ii klJr$lhi lu w.ily hrl.ir l]ousohotu D i!l!1)lt1a lo(!lr!{dc $ul t"u ffc oirtiLlt lJr as:;irlod hou$ln! bomllls Br thal lhtk be^r?hl! e.{ !?1 il tht t,e|c1 lnwl Hllll, lllo O/4. rftJ llllr titlA n,sy pn!1h4,r16 ln.rnpulet mnL!:hil\l jl:oqrrfin \rla| llnrse Eorrrros lo vsriq lod a{Att{rilt adll l6vtl o, l,!r!(!,ilt, 'fhis {oan cE! lltlrkntroE liUD, lh( O//\. rlxj 1t1., PllA lo !oa} l{t*€, .*^ hirg (W-{l ord $ntsorlr,Jy.{ifil .lrki ir dor.!r,t m llom rtrrrrn or rormor ami,royor! t0 \,6,1ty lnlixnrnlio^ dbruiaal llt 61l$h ernpuln rmiiJd.u.
us6! o{ lnlormallon to b€ OuBl$ed: HUD 16 rcq/k€d io p.olocl lho loramg irito.oBtlon ti obialns ln {rccordan 6 wllh the Prl!€qy Act of 1974, 5 U S.C. 55?a The OIA dnd lhs PHA ls also ruq\rirod l,o p@teol lho lnc.mo
Slgnaturos:
" dn_ii!'i6--xtrsaiE;r 11] 6ad U!.r
orri", r,i,iIy r'i,i"ri"" r o inii o*
Othor Fdnlly Msmbs6 16 a.d Oler6-noir.,;n.r v"mt -s rt ortt Owr odle
d&'d;6;fiffifi;IEili;;ffii?E*-_* *
Agencles To Ptovld€ lnformatlon
Sl8ta Wago lnfo.mallon Colloc(on Agonol€s, (HUD and PHA), Ihls consen( is llmlted {o wages and uncmploymont compensation you hBve recBived during podod(s)wlhln ths lasl S
yoars i,lhen you hav€ r€ceivod asgisteo houslng ben€llls.
1045-l(l Patuers Share ot lncomo. Credits, Ooductions. 6lc.
104'l-K1 Bonoflclory'8 Shar€ of lncomo, Crcdils, Dsduciions, etc,
1120S-K1 shsrshold€/s Shar€ ot Undislrlbuled Taxabl€ lncoms, Crodlts, Deducllom, 6t.,
U.S. Sooial Seqxily Adminlslration (HUD only). fhb consenl k I understand lhat income lnfomolion obtaln€d f.om hese sourcst llmltGd lo thc wage and sglf €mploymgnl ldo.rnaljon floin yoo. wlll bs us6d lo vorlfy lnfomatlon thal I Provlde in del€rmlning ln(lal curent form W,2. or contrnu€d ellgftrllily fot Gsbtod housing progEm6 and lho lewl
Nat,onal olrootory of N€w Hrres oonlatned In ttte Depadmefll ot ot bonofllE'
Health and Human Servlc€s' Ey6lem ol .ecords. ThiB consonl ls No solloh can b€ tak€n to tsrminal€, deny, 6uBpend, ar r6ducs lhe limiled lo wag€s and unemploymonl compenselion you hav6 ascblancc your household receivos bascr, on hlormalloo obtolned rec€ived durl.g pedod(s) wllhln lh6 last 5 yearc wh6n you have aboul you under lhlo cons€nl u^lll iho HUO Ofilc€, Ofice of recalvod assrstod housing benorits. lnspector ceneral (Olc) or lho PHA (vrhhhovor is appllosbi€) and
U,S. tolernal R6v6nu€ Sorvic€ (HUD only). This consont is lin led lho O/A havo hdopondBnlly vodfiodi 1) lh6 s,nolrnl of lho hcomo,
lo inlormalioa coverod in yrjur curronl lai rolurn €gs or unernploym€nt cohpeflsalion lavofued. 2) v*!6lher yrxt
rhis coneenr is ilmited ro rh€ rorhwins hro,maron thar may ifi'J;tiTJ'X":**Tirf ;ffIT:IH"",ffi#,TY; app€ar on your curent lgx feturnl rospoct to tnhjch ].ro acrtuslty rocelved Euch lnco[]o, wlgss, or 1098-5 SIst€m€ll| lor Reolpl€nts of Proc€sds fiom R€al Estato hDnsfils A pholog)py of lhe signed c{nsdnl may be ussd lo Tr€hsadloN r€$/esl a lhlrd p8(y to 96rlly any lfltolTnallon ro@lv€d uh{ror lhfti
1o99-B statement lo. Reciplenb ol P.oco6ds from R6d Estate coneont (e'9. omployer)'
BrokorE and Bart6.s €xchang€ T.ansaclbns ,O, tho O/A, or the ptl{ 6hall lnform ,o!, or 6 thkd pany which
1o99-A loformailon Rollrn for Acqll6ltlon or Absndonm6nt ol You d€Elgnate, of th6 findlngo made on th€ basb of Infornratioo
S6cufed Propedy verlllgd und6. thls @nsgnt and 6han giv€ you 8n opportunliy to
1099€ slatement for Reolpl€nts oI cedain Govemmonl cont€sl6uoh flndlng8 ln ac'ordeoce \4lth Handbook 4350 3 Rev l
Paymenis It a m€mb6r ot the ho{rs6hold ,,vho ls aoquircd to slgn the c4nsont
109g-OlV Statem€nl for Reclpl€nls o{ Dtuldeods 6nd Distrlbultons ,om ls rmable lo slgn the lorm on lims du€ io €'(enualing
iose rNr sr.{er'nt ror Reciprsnrs or rnro.,."r rncomo f,Xlfli1ffi*1""?Sfii"'ffifilljlf,l:n$;dffi,t;; 1099-i4lSC Statement fo. Reciplonls ol Mlso€llanools Eoon as possibls.
lncom€ This cons€n{ fotm €xpir€s 15 months all€r signed.
1099-OlD Sta(emeot for Reqipienls ol Originall6s{e Oisclunt
1oSS.PATR Statemeot for Rooipienls of Tar@bl€ Dlslrlbulions Recelr€d f rom Coop€raliver
1099-R Slalemont for Roclplor s of R€llrem€r{ PIIII! W2€
Stalomod ol Gamblino Winninoa
alnount lh(, tenan(r) nru$l pdy toward re6l and ullllics, llUO !s€€ tnis rnlo,matlon lo as$isl in minxioxrg cc(ain HUD profrcrllos, tc Frclcrt ths Governfiei:fs in:rnclal inlerogl, and lo ve.i{y lho acolrsay o{ the lnforrnallon lurnishsd. llUD, lho own€r or manngonlont agcnt (OlA), or n puulio lrcusrng ageo.,y (,,1{A) nray c.rrducl a (x),npurrr m:d.h to vorily lho lrlorrnatlon you provlde. I hls Inlormalion may bc r€laitsed lo npprnonate Fedtral. slato, and kcal aflcncias. wlton,olovanl. and to clv(. c(mlnn?, or regulalory inv(,3{gato,s and PrDs{rcul{rs. Hohrever, tho lol(xlrtrlion will nol bo olho.wise diiclosed or roloilscd .r(rl$l{e of ilUD, oxcct}t aE per,nftlcd or raqulrod by law You mutt provldo oll ol lho inrornr. ion aequeslod. fallu.o lo Frovld€ any inlormElion may roiult ln I dclay or rcieclton ol your olioibi,lly approlal.
Ponrltlis lor Mlsuslng lhia conBsntl l{UO lhe O/a, snd sny PHA (or any smployoo of llUO.lhe O/A, or ihe PHA) may bssubject lo p€n.ltles tor unauthorlzod dlsolo6ure6 or lmproper lsos ot Info.mollon collsctcd bssed on the con6enl {o.m.
Uso ol the a,{omolion collfilod ba$sd on lhs lornr llUD 9BB7 lE rosl.ictod lo the E[Fo6(rs cil€d on lho torm HUO 9887. Any po6oq who kn flingly or vil,fully re(tu65ts. olratls, or disck,sca soy lnrorirlallon rhdor fal8c prcl,r,rscs coocornln0 6n sppllcBnt o. tonaht oray be subi€cl h) l| rnisdurro*aor and tired nDl moro lhah $5.000.
Any opplr.rnl orlenant atfBctod by ncgligafit dlsclosurc of lnlDrrn;r{lon may brln, civll aclion for (lnnragcs. and seek othor rsll€f, es mEy be BpproDrlate. agalnst the ofilcoror smployBe ofHUD, th€ Olvll(r orth6 PHA 16$pol\slbb for h€ unnuliorizod dlsclosur€ or lmproper uso.
16r Hsndboots 4350.s Rdv-1, 4571.1, d57l,2 lt 4571.3 and HOPE llNotlc€ ol ProgBm Guld€lhl(,s
OriOlnalis retalnod on fll€ al the groloct slt€ bm liuD.88l7 (0212007)
Applicanfs/Tenanfs Consent to th€ Release of lnfomatlon Verification by Owners of Inlormation Supplied by lndividuals Who Apply for Housing Assistanco lnstructlons (o Ownals
1 , Giv€ lhe doclmBnts listed below 10 lhe applicants/tenanls to sign. Slaple or clip th6m logelher ;n ono paokage in th€ otder listed. a. Th€ HUD 98BZA Facl gheet.
b. Fo.n1HUO.9887. c. Form HUlg887-A. d - Releva4t veriflcations {HUD Hsndbook 4350.3 Rev. 1).
2. Verbally lnform appllcants and tenants th6t a. Th6y may 1ak6 th€se lorms hom6 wilh lhem to reEd or to
dlgcuss,r{h B lhlrd party oiiheLr choice and to r6tu.n to slgn lhem on 6 dale they hav6 workod oui with you, snd
b. I thoy have a dlsab]llty that pr6venls thom from readlng and/ or signing any cons€nt thal you,lhs Ownor, srO reqlhsd lo provld€ rBasonablo accomrnodatlon6.
3 Owners arg aequi.€d to gile naah houschold a copy ol lhe HUDSSSZA Faci Sthrsl, lorm l{UO-goB?, and torm HUD-9887-A a{ler oblaining th6 raquked afrlicanisltenanls signature(s). Also. ownsrs musl glve the appllcao*iltenants 6 cop., of tho gignfld lndlv{dual verlficstion torms upon thoir rBqussl
lnatructlons (o Aptrllcanl3 ghd Tenanls Thls I'orm HUD.98{17-A conlains customer informqlion and
proiecllons concern,no ih6 HuD"rsqulred verlflcallonG thal Ovrners musl perlorm, 1 Read thls materlal which orplains:
'HUO'S req!kemenls concornlng lh€ raloasc of informollon, and
. Oih€t clstomor proleclions. 2. Sl€n on tho last pag6 ihs(:
. w { h.vn raa.i lhls {..In. o.
. iho Ollner of a third parly ol your choic, has expldn6d lt lo yo!,
! yotr consenl 1o lhe rslease of lnto{matlon for lhe purposes and uses descrlbod.
Purposo ol Reqlirlng Conssnl.lo lhe l{4loaie ol ln{ormallon ln l,igfinQ lhis crnsrnl forn], yo{J ,rF airlhDriTai$ lhu Owner ol lhp
l\ou$iJt(r rroi{:ci io whrch you 0r{r applyinq fo:.ssrslahao lo roqL]esl inlororilliort kr,$ a third pady i,!.rrt y.ro HUD rn.iLrir4r lht holslnq o!./n{rl lo vcrily lll ol lhe {niorfirlio! yo! provide lhat alfeols you, Bli0i!1i,1! an. l.-.vol .i lten€l{s lo erl:]ln.j lh;l yor i}ru eiiglhlc lor asslstod nouslng bcnclira and thsi ilrsic henclils rrr 1el at lho correcl lovels- llfior lhc requosl ol tlre HUU gli!!:o or lho PllA (as Contracl Admiirs{ra1o,) lirg }r(4lrins Owner lnay ntovidE Hll0 or lha PHA wilh lhc nlormalio^ yoo hole slrhmillod and lhg lnlonratioo th€ Ownsr reooives undor lhis con6enl.
Us€s o{ in{ormslion to b€ Obtaln6d Ths irrl.ridual listed on th€ varileatlor fornr mny roquosl arrd
.ece!!c the lnlorftalion rcqires{ed by tils verilk,atian, $lJbiocl to lhe lirnltslions ol lhi, for.ir. i'it,t) is rcquirod Io prot.rcl lhe inmrn* inlon\atko il olltairs rn |lcco.danrc with lho irrivaey Act ol 1$74,5 U.S-C. :41a. Th. Ov/n6r and lh6 PllA are plso rcqukod la, orotuol rhe incoftn inJbrrnallort lhsy oblail ir aocord:.nce wilh any appllcaUle glato p.ivacy lnw. SllollC tho lJwnar ,cc.rvo inlorflralion tom o t,rlrd prdy thal is inrrrLslsienl wilh llie inlot.nrlion you hav€ provriod, lhe O*,rr(,r is r€q!irxd k, nolily yor.r in ,rrillng id.nrlltylrtg lho rntomation b(lev.:{1 10 i}e rnc.ortecl. If thls should o.cllr, you will h6v0 lhe opiro(unilt lo meet wilh lhe Ownor 10 dlsauss oly d16crspancl6$.
Who Must Slgn tha ConslJnt Fornl Each nrofnler of yoLrr noirsehold wllo is eL loait 19 yea$ ot 8Be. and
Ea.|' ramlly lrc:rd, s,xnrsc or co-h!t,(i, re(ardlss6 of allc nrusl sl$r lhe rdkrvanl u)fiscnt lo.nrs at lhr i,rital codi{(.don. at €ach rer-ortilicalton and at earf inlorin cGrlitication. ri 6pp,icahl€ ln addltlon. vrhen new l){iull &efilbRrs jo,h lhc household and lthen rrFrr'nHrs oi ri's'ruLle,,old occomo i6 /d,r5 (,; dgu r,'ty,rds, a,su
slgn lhe rslovanl cons€nl form6
PftT6ons who spply for or rocelve asslsillflco und€r th€ tollowing prcgrams musl slgn lhe relelanl consenl lorfilsl
R€ntal A66lstance Prooram (RAP)
R6nt Suppldrnent secllon 6 Houslng AssislBnce PEymonls Programs (adminiBlored by
the Otlic4 of Housing) S8ctlon 202
Sacllons 202 and 811 PRAG
Secfion 2021162 PAC Soction 221(d)(3) Below tu16*et lnteros( Ral6 Sectlon 236 HOPE 2 Hoine ow^srshlp ol [4uliifarnily Unils
U.S, OoperlrRont of Hou6lng .nd Urban Devalopmolrt Olil€o of Houeing Federal Holslng Commlssloo€r
Authorlty fo. Raqulrhg Appllcanfs/Ton.nt's Con.ont to tho Roloarq ot lnlorm.llon
S6cllon 904 ot th€ Stewarl B, MoKhnoy Homd66s Asslslanca Amondmonls Acl ol 1988, a6 amondod by srellon 903 o{ ihe Houslng ird Cqmmunlly Devslopment Ac{ of '1992. Ihls ia$ i6 found al42 U.S.C.
L,rformallon thal yo! have provldod whloh wlll aff€cl th€ amountol ren! you pay.'lirc irforlnsfon inclsdeElncofirs and assels, :iuc\ as $alary, wellaro bencli{s. and rotsrcsl eamed on saving$ irccoJnts. Thoy alsoinclurio ce,1 n
adl!slrn€nls toyou.lrcl)me, such 6s the allov,/ahcos for d6psndenls anrj lor irou:;sholds whoso hoods o r 6 pou6ss are ekj Brly hand looppsd, ot d lsatrl,ldi
and alloy".ances {or chlld cars expensos, medlcolexpens€s, snd handlcap a65lst?nc€ oxp€nse6-
rel. Handbooks 4350.3 B6\tr1, 4571,1,4571.2 & 4571.3 snd HoPE llNolics olProgram Gulddlnos
Orlglnal16 rotaln€d on llle allho prcjoct sll€ lorft HUO-883/-A (02/?007)
lo vaIify salrry anal wosro or L{}y.ri ol L!.(]nollls.
Failure to Sien the Consent Fomr Failure to sign any required consent form may result in the denial of assistance or termination of assisted housing benefits. lf an applicant is denied assistance for this reason, the O/A must follow the notification procedures in Handbook 4350.3 Rev. 1. lf a tenant is denied assistance for this reason, the O/A must follow the procedures set out jn the lease.
Conditions No action can be taken to terminate, deny, suspend or reduce the assistance your household receives based on information obtained about you under this consent until the O/A has independen[y 1) verified the information you have provided with respect to your eligibility and level of benefits and 2) with respect to income (including both eamed and unearned income), the O/A has verified whether you actually have (or had) access to such income for your own use, and verified the period or periods when, or with respect to which you actually received such income, wages, or benefits.
A photocopy gf the signed consent may be used to request the information authorized by your signature on the individual consent forms. This would occur if the O/A does not have another individual verificaiion consent with an original signature and the O/A is required to send out another request for verification (for example, the third party fails to respond). lf this happens, the OiA may attach a photocopy of this consent to a photocopy of the individual verification form that you sign. To avoid the use of photocopies, the O/A and the individual may agree to sign more than one consent for each type of verification that is needed. Th€ O/A shall inform you, or a third party which you designate, of the findings made on the basis of information verified under this consent and shall give you an opportunity to contest such findings in accordance with Handbook 4350.3 Rev. 'l.
The O/A must provide you with information obtained under this consent in accordance with State privacy laws.
lf a member of the household who is required to sign the consent forms is unable to sign the required forms on lime, due to extenuating circum-
stances, the O/A may document the file as to the reason for the delay and the specific plans to obtain the proper signature as soon as possible.
lndividual consents to the release of information expire 15 months afler they are signed. The O/A may use these individual consent torms during the 120 days preceding the certirication period. The O/A may also use lhese forms during the certification period, bul only in cases where the O/A receives informatlon indicating that the information you have provided may be inco.rect. Other uses are prohibited.
The O/A may not make inquiries into information lhat is older than 12 months unless he/she has received inconsistent information and has reason to believe thal the iniormation that you have supplied is incorrect. lf this occuIs, the O/A may obtain intormation within the last 5 years when you have received assistance.
I have r6ad and undeEtand this info.mation on the purposes and uses of Information that ls verified and consenl to lhe release of lnformation fol these purposes and uses.
Name of Applicant or Tenant (Print)
I have read and understand the purpose of lhis consent and its uses and I understand lhat misuse of this consent can lead to personal penalties to me.
Sherman Hills Holdings LLC
Asst Manager
Signature & Date cc:ApplicanUTenant Owner file
Penalties for Misusing this Consent:
HUD, the O/A, and any PHA (orany employee oi HUD, the O/A, or the PHA) may be subject to penalties for unauthorized disclosures or improper uses of informatlon collected based on the consent fom-
Use of the information collected based on the form HUD 9887-A is restricled to the purposes cited on the form HUD 9887-A. Any person who knowingly orwillfully requests, obtains or discloses any information under false pretenses concerning an applicant or tenant may be subject to a misdemeanor and {ined not more than $5.000.
Any applicant or tenant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officel or employee of HUD, the O/A or the PHA responsibl€ for the unauthorized disclosure or improper use.
ref, Handbooks 4350.3 Rev. 1 , ,1571 .1 , ,1571 .2 & 4571 .3 and HOPE ll Notlce of Program Guidelines
x
Original is relained on file at the project site fom HUD4887-A (022007)
Title
I
i
Date:
Oear
Seclion 214 ofthe Housing and Communit], DevelopmentAd of '1980, as amended, prohibjts the Secretary o, HUD from making financial assistance available to persons otherthan U.S. citizens or nationals, or certain categories of eligible noncitizens, in the following HUD programs:
a. Section I Housing Assistanc€ Payments programs;
b. Section 236 of the National Housing Act including RentalAssistance Payment (MP); and
c. Section 10 URer{ Supplement Program.
You have applied, or are applying for, assistance under one oflhese programs; therefore, you are required to declare U.S. Ciiizenship or submit evidence of eligible immigration status for each of your tamily members forwhom you are seekiog housing assistance. You must do the following:
1. Complete a Family Summary Sheet, using the attached blank format to list allfamily members whowill reside in the assisted unit.
2. Each family member (including you) li9ed on the Family Summary Sheet must clmplete a Citizenship Declaration. lf there are 1O people listed on the Family Summary Sheet, you should have 10 completed copies of the Citizenship Declaration. The Citizenship Declaration has easy-to- follow instruciions and explains wttat, il any otherforms and/orevidence must be submitted with each Cfu'zenship Dedaratton.
3. Submit the Fami,y Summary Sheet, the Citizenship Declarations, and any otherforms and/or evidence to the name and address listed below by inrcrview daie
Slnwtli$slpau* 3ut?sfltattM W1tut?,lMlfr@
214 Owne/s Notice 1 Page 1 oi2
2fiat t70A*512t f.qr7&EzeTrjn
I I
I l
This Section 214 review wjll be completed in conjuoc{ion with the verification of other aspeds of eligibility for assistance. lf you have any questions or difficully ifi completing the attached items or determining the typ€ of doalmentation reqlired, please contaci
51i-ax-5124 He/she will be happy toManagment at assist you. Also, if you are unable to provide the required documentatjon by lhe date shown above, you should immediately contad th6 ofFrce and request an extenslon, using the block provided on the Citizenship Oeclaration Format. Failure to provide this information or establish eligible status may resuft in your not being considered fur housing assistance.
It this Seclion 214 review results in a determination of ineligibility, you will have an opportunityto app€althe decision. Also, if ihe linat de{ermination concludes that only certain members oi your family are eligible for assistance, yourfamily may be eligible for proration of assistance. That means that wtlen assistance is available, a reduced amount may be provided foryourfamily based on the number of memberswho are elisible.
lf assisGnce becomes available and the other aspects of yow eligibility review show that you are eligible ,or housing assisiance, that assistance may be provided to you if at least one member of your household has submitted the required documentation. Follor/ing verification of the documentation submitsd by allfamily members, assistance may be adjusted depending on the immigBtion status verified- You will be conlacled as soon as we have fuather jnformation regarding your eligibility for assistance.
Owner/Owne/s Agent Signature Date
214 Owneis Notice 1 Page 2 af2
I4r\Ill-jIlllItlMAEY_S.!1!-!:I
i Nar Drsct{nlrN;\TE olt rilE s.\sls oP tllNDIc\P;[D srA'TUs IN1tre ltrMrsqo] oR act!ss ro oR t"
^ Y,}ii'iiiiii 6ii,*-n.ovi rl r i'r. rrs yrt-o'r:iiii o ss'sr no rt'oceei'as aND Acr*r'Es'
DECLARIIIO}I I.ECEND
? - Non'Cilir.r ,lr[ .tiiblc iobrgnlin Jtrth 3 " Noa codendhg clq:ibL lmEigr'6o! t(lt{t 6
o\Dl!EB'slll!.A![aBI
u.S. Oeparhrent of HoEing and urban Developme.n
OMB Appro\€l No. 2502-mO+ (Exp.06/302011
Sherman Hills Holdings LLC
The Aspen Companies Section-8 _
.m. of fiaid ot Hous.hold iLrn. ot Househokl Xldnb€r
:.i-.!:
Narive Ha*a.iian or Other Pacific lsiandei
wlrile
O&er
*I)tfinil iop! o f .hcs.' clr(eo ri.s m?! br IcuBd on lhl: ft! ':r* sidr.
?h(re is no peorll\'for pel\ons who d! sol corlolcte tIc ionn.
Slgnatule Date
fo.m HUD27061-H (9/2003)
Pub$. frlonilg burao tbr rnir @ll.cli@ i. .sti@!d ro aG.gc 10 inn.s D6 Gpce, iachlding lhc 6me for Eh.einE r6!.udroE!, s.nitr8 aisring dr,l soure, g.rh6irg ed rBjntsi,irg 6. dara nc.d.d, ed complcring ad diryre ihc .oltecrior of iilotualiotr ftie jnfod.no. is rquirc! to obr6:n b.rE6ls lrld DludEi. HUD m.y., not @Dd rlis hto@ariol! &d t"ou d. nor Equilcd :o @np!d. rhis fm! ulcs! il ditplqs, @mtly varid OI@ coftd num[cr ftir infomrrioo i! aulhdiird bt th. U S- rlonsing .4d of I 93 7 a doded, rI( tlo$ine dd U.b$ Rurat Rc.ov..y Acl ol t 9El @d HoEitrg ad C(rmDiry Dcv.loprncnr Iechnal ABadmalt' of I99{. lhis i.lomdoi is nddc,j $ b. ircomrtia.. wiin O[,tB{art id.trogts Io Ethrcity dd A@ dego.i6 for @rdiDg $. J0059 Drda R.{uiroDsrs ro ltUD. O1rnara{crr6 Dcr oftr th. orpor&url ]D thc had ?dr,i co- head of @h lDBch.ld to '!cllBri&' d!'ring rhc a9'tjcltio r.r.diw or Ie6. ligning tn-pLc! !fi!,!r ,rrsr so&ptcr€ dlc ,b@t 6 F,1 of tniit ne{r fidim d tuul rc+.ri6etior! rhis tteu will ailow t}c dnr/a!41 to @llcct dE @&d i!frda!6 oD au oo6}ers ,ar}. toEchold. Conll.l.d do16dt' shorld 1,. stgkn hgdfi.r 6r @h toulho,d ed pled iD $. nouehold s tilc. P{cfis or E@dios d to @mpl.ie tr5€ *lf-qrincnioa &r childfrn urd6 dtc a8. of 18 One stn h iicv.kp[. fEds e lroriC. od dr lppopri.te systcn l+gad6 hM b6 idll.ndr.A o*@dag@6 will b. E{uiEd io ..?orr dE a.. a]d .rrDi.iry .l{. .rdlro.irty io d,. I}.ACS alcn Renral 4isisEne CcdificalioD sy$m) This jnlonmion is cmidaai nor,scDsiiiyc ad dors no EquiE ay srftiel Dtor{rior
lnstructions for the Race and Etllnic Data Reporting (Form HUD-27061-H)
A. CeBeral In3lructions:
This fora is to be completed by individuals risbing ro be served (applicants) and those tlrat arc curefily served (teuaots) in housing assisted by the Depar[nent of Houstrg and Urban Development.
Owner and agents are required to offer the applicanvtenant the optioD to complete the form. The form is to be completed at inirial application or at lease signing. ln-place lenaots must also be offered the opportunity to complete the forE as pan of the next interim or amual recertiflcatiorl Once thc form is completed it need not be completed again udess the head of household or household composition changes. There is no penalty for persons vho do not complete the folrn. Howevet the ou,.ner or agent may place a note in the tenant file staung the applicant/tenant refused to complete the form. Pareuts or guardia[s are to completc the form for childreD uDder the age of 18,
The OIIice ofHousing has beea givea permission to use this form for gathcrirg race ald ethnic dara ia assisted housing programs. Completed documeuts for the entire household should be stapled together and placed in rhe household's file.
l - -fhe two etlnic categories you should choose from are defuled below. You should check one of the two categories.
1. Hispanic or Lrtino. A persoa ofCubar, Mexicaq Puerto Rican, Soutl or Cental American, or otlrer Spanish culture or origin, regardiess ofrace. Tbe term "Spanish origin" can tle used in addition to 'Ilispanic" or "[atino."
2. Not HispaDic or Latiro, A pcrson Dot ofCuban, Mexical, Puedo RicaD, South or Ce!.tral American, o&er Spanish culn[e or origiD, regardless ofrace.
2. The five racial categories to choose Aom are defined below: You should check as maay as apply to you.
1. Americau Indi.an or Alarka Nstive. A person haviog origins jn any ofthe original peoples ofNorth and South America (including Cental America), and who maintains tribal afhliation or commuDity attachment.
2. Asian. A person having origins in aoy oftbe originai peoples ofthe Far EasL Southeast Asia, o! the Iodiao subcontineat including, for example, Cambodia, Cbina, Indi4 Japao, Kolea, Malaysi4 Pakistao, the Philippine islands, ThailaDd. and Vietnam
3. Black or AfricaD Alneric![. A peBon having origins ia any of the black racial goups ofAfrica. Temrs such as "Haitian" or'Negro" can be used in additiol to "Black" or "African Artrerican."
4. Native Ilawtilan or Other Pacific Islatrder. A person having origios in any oftie original peoples of Hawaii, Guam, Samoa, or othe! Pacific Islands.
5. Whits" A person having origins in any ofthe original peoples of Europe, rhe Middle East or North Africa
lom HUD-27061-H (92003)2
Citizen,t{on-citizen Declaration
INSTRUCTIONS: Complete this Declaratioa fot esch meDber oftte [olsehold listed otr tlrcFamily SumD.ry Steet
LASTNAME
RECISTRATION NO
ifapplicabte (this is an I Idigit number found on DHS
NATIONAIITY
-(Elter
the forc,gn ration or.ountry to which you owe legal allegiance. This is normally burnorrlways lhe country ofbirh.)
Thle 18, Sec.ion t00l of*," U.S.CoE faudule$ vatemcrrs ro any depanrnent oflhe unired slares covemment, HUb, d,e FH.+ ind any owneir", *y
"i,pioy""ofIUD' the PHA or Lhe o\trer) may be subj€ct to penalties for uauthonzed disctosures or improper uses of intimatioo collected based on th€ consent form. Us€ ofthe informatio! collected bascd on fiis verificntion form is rcstricEd ro the putPoses cited above. Any Pcrson who lro*ingly or willfirUy requesrs, oblains or disclos€s ary informarion uader fa.lse prctsDs.s corceming an applicarr o. parti.ip.nt may be subject toa misdcn.anor and fincd not more rhan ss,o00. AryaPllicant or panicipart affected bl, negrigent disclosure ofinforD]arion may bring civil action for daJnages, ard seek oihcrrell€f, as may be appropriate, against rhe olficcr or employee otHUD, the iHA ; Lhe own€r responsible for the unaulhorjzed disclosutc ot ihProPcl use. Pcnalty provisions for mrsusiDg rhc socral sccurit) Dumtrer arc cooraircd in thcsocialsEDritv Act at208 (a) (6), (7) and (8). vioiation of6ese Fovis;o'ns ae c;tea as vio'tatons ofa2 u.s.c- aos(a)(o.(?) and (8).
(lo be entered by owDer/agetrt ifand rphen received)
hereby decla.e, undet
(p nt or type first name, r0iddle initial,lasr narne):
INSTRUCIIONS: Compl€te the Declarxtion belo,r, by printing or by b.pin8 the person,s firsr name, middle iditial, and-last Deme in fie space provided. Theo revicw rle b'iocks
"rro*"Lroi -a **plete either brocknuftber 1, 2, or 3:
DECT.ARAIION
FIRST NAME
soclAL
A-LIEN
tlt\ 1l I I rS ti llt \ \t \t \(, I l \ ttrR\t
E1.
A citizen or uatiotral of the Uuited Stqtes.
Sign and date below and retuft to thc name and address specified io &e anached notificalion lefter- Ifthis block is checked on behalfofa child, tle adult who will residc in thc assisted unit and who is responsible forthe child should sign ard dat€ below.
Date
fl Check herc if adult signed for a child,
n 2. A DoEcitizen with eligibte ididgr.tioD slstus rs evidenced by otre ofthe alocuments list€d below:
Iflou checkad this block, you,ra1st s bmil the following documents:
From nontitizens claiming eligible status who is 52 or older:
a- This siped declaration ofeligible immigration st&tus and b. Proofofage
Fmm non-oitizens claimiflg eligible status wtto is not 62 or older
a. This signed declaration ofcligible immigratio[ st trs 6rd b. Verification CoDsent FoIm
AND
c One oftie following documents:
i. Form l-551, Permaner{ Resident Card. 2, Form l-94, Arrival-Depature Record annotated wifi one ofthe following:
a. 'a.dmitted as a Refirgee Pursuantto S.ction 207"1 b. "Sectiott 208" or "Asylum"; c. "Section 243(h)" or "Deportation staycd by Attomey Ceneral,'j or d. "Parol.d Pwsuant to Sccrion 212(dX5) ofthe INA.,'
3. Form I- , Arrival-Deparrure Record (wirh no annotation) accompanied by one ofthe following: a. A fiosl court decision granting asylum (but oniy ifno appeai js takeD)l b. A letter fiom an DHS asylum officer gmnting asylum (if application was fiied on or afler October
I , I 990) oi iiom an DHS district director gmnting asylum (application filed was befoe October 1, 1990);
c. A coufi decision granring q,ilhholding ofdeportatioq or d. A lctter aorn an asylum ofrcer granting wirLholding ofdeportarion (if application \Nas filed oIl or
a{ler October l, 1990). 4- A r€ceipt issued by the DHS indicating that an application for issuance ofa replacemeni doculrle irl
one oftle above-listed categories has been made and that the applicant,s ertitiemenr to the document las be.n verified.
Plge 2 of3
Citizen4{on-citizen Declaretion
5. Other acccptable evideBce. If other documents ar! detenoincd by the DHS to constirute acceptable evideflce ofeligible immigralion status, they eirill be adnounced by nolice published ir the Federal Register.
If this block is checked, sign ald date below and submit the documentation required above \rith this doclaration a$d a vedfication cotls€nt fomat to the name and address specifi€d in the attaohed notificadon. Ifthis block is chccked oB b€half ofa chil4 the adult who will reside iD lh€ assined unit and who is responsible for the child should sign and date bslow, If for any reasorq the documents shown il subparagraph c above are ,ot currently availablg complete the Rcquest for Ext€nsioo btock below.
Signature Date
EXTENSION
I hcreby certify thal l ara a noncitizen with eligible inmigration status, as noted in block 2 above, but the evidence needed to support my claim is temporarily unavailable- Ti€refore, I am requesting additioDal time to obtain the necessary evidence. I fu.thcr ccrt8 that diligent and prompt eliorts will be undertaken to obtain this evidence.
Signature Date
E Check her. ifadult signed for a child.
tr 3. I aD! Doi coEterdiEg eligible immigration status rDd f undeNtrnd ttat I am trot eligibl€ for holrsitlg assiatance.
Ifyou checked this block, the person nalued above is rot eh'gible fo. assistance. Sig$ ard dare below ard forwaid this format to tho naJne and address speoified in thc attached notificatioa. Ifthis bloek is checked onbehalfofa child, rhe adult *4ro is responsible for the child should sign ard date below.
SignaturE
Date
TIIINK AIIOtrTT TIIIS... IS ltllilllD IYOB'I'II IT?
Please read and initial
Do You Realize...
lf you commit fraud to obtain assisted housing from HUD, you could be:
o Evicted from your apartment or house. . Required to repay all overpaid rental assistance you received. . Fined up to $10,000. . lmprisoned for up to five years. . ProhibiteJ from receiving future assistance. . Subject to State and local government penalties.
Do You Know..,
You are committing fraud if you sign a form knowing that you provided false or misleading information.
The information you provide on housing assistance application and receftification forms will be checked. The local housing agency, HUD, or the Office of lnspector Ceneral yLl] check the income and asset information you provide with other Federal, State, or local governmenls and with private agencies. Certifying false information is fraud.
So Be Careful!
When you fill out your application and yearly recertification for assisted housing from HUD make sure your answers to the questions are accurate and honest. You lqqq include:
All sources of income and changes in income you or any members of your household receive, such as wages, welfare payments, social security and veterans' benefits, pensions, retirement, etc.
Any money you receive on behalf of your children, such as child support, AFDC payments, social security for children, etc.
form HUD-i14'l (2r20o5]-
Any increase in income, such as wages from a new job or an expected pay raise orbonus.
All assets, such as bank accounts, savings bonds, ceftificates of deposit, stocks, real estate, etc., that are owned by you or any member oi your householcl.
All income from assets, such as interest from savings and checking accounts, stockdividends, etc.
Any business or asser (your home) that you sold in lhe last two years at less than fullvalue.
The names of everyone, adults or children, relativcs and non relatives, who are livingwith you and make up your household.
(lmportant Notice for Hurricane Katrina and Hurricane Rita Evacuees: HLlD,s repotling rcquiremcnt. may be lemporarilV waived or suspended bn. our" ot y.,r, circumstances. Contact the local housing agency bcfore you complete the housing assistance application.)
Ask Questions
lf you don't understand something on the application or recertification forms, arways askquestions. lt's better Io be safe Ilran sorrv.
Watch Out for
. Don't pay money Io have someone fill out housirrg assistance application andrecertification iorms for you.
. Don't pay money to move up on a waiting list.. Don't pay ibr anything that is not covered by your lease.. Cet a receipt for any money you pay. . Ccl..l.\ rillen e\plandtion i[;ou are requirecl to pd! tor dn]thing otller lhdn renllm,rlnlenanco or Litilit) ( h,rrgesr.
Report Fraud
l[ you know of anyone who providerJ false infornration on a HUD housing assistance application or recertification or if anyone tels you to provide farse infor-"ation, report thalperson to,the HUD Oliice of rnspector cenerai Hotrine. you can ca the Hotrine tofiJreeMon(iay through Friday, lrom 1O:00 a.m. to 4:30 p.m., Eastern Time, al 1_BOO_347_]735. You can fax jnformation to (2O2) 7OB_4829 or e-mail ii to llc2tiin1,-e]ll Licloig.gqy. Vou canwrite the Hotline at:
HUD OIC Horline, CFt 451 7th Street, SW Washington, DC 20410
form HUD-1141