Warren Housing Authority

Instructions for the Race and Ethnic Data Reporting (Form HUD-27061-H)
A. General Instructions: This form is to be completed by individuals wishing to be served ( app Ii cants) and those that are currently served (tenants) in housing assisted by the Department of Housing and Urban Development.
Owner and agents are required to offer the applicant/tenant the option to complete the form. The form is to be completed at initial application or at lease signing. In-place tenants must also be offered the opportunity to complete the form as part of the next interim or annual recertification. Once the form is completed it need not be completed again unless the head of household or household composition changes. There is no penalty for persons who do not complete the form. However, the owner or agent may place a note in the tenant file stating the applicant/tenant refused to complete the form. Parents or guardians are to complete the form for children under the age of 18.
The Office of Housing has been given permission to use this form for gathering race and ethnic data in assisted housing programs. Completed documents for the entire household should be stapled together and placed in the household's file.
1. The two ethnic categories you should choose from are defined below. You should check one of the two categories.
1. Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term "Spanish origin" can be used in addition to "Hispanic" or "Latino."
2. Not Hispanic or Latino. A person not of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
2. The five racial categories to choose from are defined below: You should check as many as apply to you.
1. American Indian or Alaska Native. A person having origins in any of the original peoples ofNorth and South America (including Central America), and who maintains tribal affiliation or community attachment.
2. Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
3. Black or African American. A person having origins in any of the black racial groups of Africa. Terms such as "Haitian" or "Negro" can be used in addition to "Black" or "African American."
4. Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
5. White. A person having origins in any of the original peoples of Europe, the Middle East or North Africa.

Race and Ethnic Data Reporting Form
Office of Housing

U.S Department of Housing and Urban Development

0MB Approval No. 2502-0204
(Exp. 613012017)

Name of Property
Project No.
Address of Property

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Warren Housing Authority

Name of Owner/Manager Agent

PHA
Type of Assistance or Program Title

Name of Head of Household

First NameLast Name
Name of Household Member

First NameLast Name
Date

MonthDayYear
Ethnic Categories*

Hispanic or LatinoNot-Hispanic or Latino
Racial Categories*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOtherPrefer Not to Answer
Signature

Clear
Date

MonthDayYear

ONE STRIKE YOU'RE OUT AGREEMENT
Amended October 22, 2018

I understand the Warren Housing Authority has adopted a Zero Tolerance Policy concerning drugs and crime.
I understand just one incident violating this agreement:
For PHA unit it will be ON OR OFF THE PREMISES
For Section 202/8 unit it will be ON OR OFF THE PREMISEs
For Section 8 HCV it will be ON OR NEAR THE PREMISES
(meaning whether the head of household or household member (s) are in town, out of town, in the state of Arkansas or out of the state of Arkansas; for the guest only applies if the guest violates the policy while they are visiting the tenant unit)
It will result in termination of my tenancy or application with the Warren Housing Authority-whether it is committed by myself, any household member or any guest on the premises with the household consent. Also, I do understand that the Warren Housing Authority has the right to conduct a criminal background check on anyone eighteen years of age or older that is on my application or lease agreement.
I hereby agree not to be involved in any criminal activities on, off or near any premises and if I am housed the entire household promise to maintain a crime-free and drug-free unit (Section 8 unit, Section 202/8 or Public Housing unit) at all time.
Head of Household

Clear
Date

MonthDayYear
Other Household Adult

Clear
Date

MonthDayYear
Other Household Adult

Clear
Date

MonthDayYear
Other Household Adult

Clear
Date

MonthDayYear
Housing Representative

Clear
Date

MonthDayYear
@media print{ .pagebreak { page-break-before : always; page-break-inside : avoid; } }

REQUEST FOR EXTENSION

I hereby cenify that I am a noncitizen with eligible immigration status, as noted in block 2 above: but the evidence needed to support my claim is temporarily unavailable. Therefore, l am requesting additional time to obtain the necessary evidence. I fur1her cer1ify that diligent and prompt efforts be undertaken to obtain this evidence.
Signature

Clear
Date

MonthDayYear
Check if adult signed for a child:

Yes
3. I am not contending eligible immigration status and l understand that I am not eligible for financial assistance. If you checked this block, no further information is required, and the person named above is not eligible for assistance. Sign and date below and forward this format to the name and address specified in the attached notification. If this block is checked on behalf of a child, the adult who is responsible for the child should sign and date below.
Signature

Clear
Date

MonthDayYear
Check here if adult signed for a child:

Yes

a.Verification Consent Format (see Sample Verification Consent Form in Exrubjt 3-6).

AND

b.One of the folJowjng documents: (J)Foml l-55), *Pennanent Resident Card*

(2) Form 1-94, Arrival-Departure Record, with one of the following annotations: (a) "Admitted as Refugee Pursuant to section 207"; (b) "Section 208" or "Asylum"; (c) "Section 243(h)'' or "Deportation stayed by Attorney General"; or (d) "Paroled Pursuant to Sec. 212(d)(5) of the INA."

(3) If form 1-94, Arrival-Departure Record, is not annotated: it must be accompanied by one of the following documents:
(a) A final court decision granting asylum (but only if no appeal is taken);
(b) A letter from an DHS asylum officer granting asylum (if application was filed on or after October ] , 1990) or from an DHS district director granting asylum (jf application was filed before October 1, 1990);
(c) A court decision granting withholding or deportation; or
(d) A letter from an DHS asylum officer granting withholding of deportation (if application was filed on or after October l, 1990).

(6) A receipt issued by the DHS indicating that an application for issuance of a replacement document in one of the above-listed categories has been made and that the applicant's entitlement to the document has been verified.

(7) *Other acceptable evidence. lf other documents are determined by the DHS to constitute.acceptable evidence of eligible immigration status, they will be announced by notice published in the Federal Register.*

If this block is checked, sign and date below and submit the documentation required above with this declaration and a verification consent format to the name and address specified in the attached notification.If this block is checked on behalf of a child, the adult who will reside in the assisted unit and who is responsible for the child should sign and date below.

If for any reason, the documents shown in subparagraph 2.b. above are not currently available, complete the Request for Extension block below.
Signature

Clear
Date

MonthDayYear
Check here if adult signed for a child: I

Yes

Warning: J8 U.S.C.1001 provides, among other things, that whoever knowing]y and willfully makes or uses a document or writing containing any false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any department or agency of the United States, shall be fined not more than $10,000 imprisoned for not more than five years, or both.

The following footnotes pertain to noncitizens who declare eligible immigration status in one of the following categories:

2/ Eligible Immigration status and 62 years of age or older. For non-citizens who are 62 years of age or older or who will be 62 years of age or older and receiving assistance under a Section 214 covered program on June 19, 1995. If you are eligible and elect to select this category, you must include a document providing evidence of proof of age. No further documentation of eligible immigration status is required.

3/ Immigrant status under §§ 101 (a)(15) or 101 (a)(20) of lNA. A noncitizen lawfully admitted for permanent residence, as defined by §101 (a)(20) of the Immigration and Nationality Act (INA), as an immigrant, as defined by §101(a)(l5) of the INA (8 U.S.C.] 10(a)(20) and 110(a)(15), respectively [immigrant status]. This category includes a noncitizen admitted under § §210 or 210 a of the INA (8 U.S.C. ] 160 or l 161 ), [special agricultural worker status], who has been granted lawful) temporary resident status.

4/ Permanent residence under §249 of lNA. A noncitizen who entered the U.S. before January 1, 1092, or ;such later date as enacted by law, and has continuously maintained residence in the U.S. since then, and who is not ineligible for citizenship, but who is deemed to be lawfully admitted for permanent residence as a result of an exercise of discretion by the Attorney General under §249 of the INA (8 U.S.C. l 259) [amnesty granted under INA 249]

5/ Refugee, asylum, or conditional entry status under §§207c 208 or 203 of INA. A noncitizen who is lawfully present in the U.S. pursuant to an admission under §207 of the INA (8 U.S.C. 1] 57) [refugee status]; persuant to the granting of asylum (which has not been terminated) under § 208 of the INA (8 U.S.C. 1158) [asylum status]; or as a result of being granted conditional entry under § 203 (a)(7) of the INA (U.S.C. ] ] 53 (a)(7)) before April 1, 1980, because of persecution or fear of persecution of account of race, religion, or political opinion or because of being uprooted by catastrphic national calamity [conditional entry status]

6/ Parole status under §212( d)(5) of INA. A noncitizen who is lawfully present in the U.S. as a result of an exercise of discretion by the Attorney General for emergent reasons or reasons deemed strictly in the public interest under §212(d)(5) of the INA (8 U.S.C. ] ] 82(d)(5)) [parole status].

7/ Threat to life or freedom under §243(h) of INA. A noncitizen who is Jawfully present in the U.S. as a result of the Attomey Generals withholding deportation under §243(h) of the INA (8 U.S.C. 1253(h)) {threat 10 life or freedom].

8/ Amnesty under §245A of INA. A noncitizen lawfu11y admitted for temporary or permanent residence under §245A of the INA (8 U.S.C. 1255a) [amnesty granted under JNA 245A]

APPENDlX C. MODEL DECLARATION OF SECTION 214 STATUS

Notice to applicants and tenants: In order to be eligible to receive the housing assistance, each applicant for, or recipient of, housing assistance must be lawfiµly within the U.S. Please read the Declaration statement carefully and sign and return to' the Housing Authority's Admission Office. Please feel free to consult with an immigration lawyer or other immigration expert of your choosing.

INSTRUCTIONS: Complete this Declaration for each member of the household listed on the Family Summary Sheet
Name

First NameLast Name
Relationship To HOH:
HOH Sex
Date of Birth

MonthDayYear
SSN:
Alien Registration No.
Addmision #: if applicable (this is an 11-digit number found on DHS form 1-94, Departure Record) Nationality (Enter the foreign nation or country to which you own legal allegiance. This is normally but not always the country of birth.) Save Verification No. (to be entered by owner if and when received)
DECLARATION
I, First Name Last Name hearby declare, under penalty of perjury, that I am (print or type first n·ame, mid.dle inlfiai􀀳 last name)
A citizen or national of the United States.

Yes
Sign and date below and return to the name and address specified in the ·attached notification letter. If this block is checked on behalf of a child; the adult who will reside in the assisted unit and who is responsible for the child should sign and date below.
Signature

Clear
Date

MonthDayYear
Check here if adult signed for a child:
A noncitizen with eligible immigration status as evidenced by one of the documents listed below:
NOTE: If vou checked this block and you are 62 years of age or older: you need only submit a proof of age document together with this form and sign below:
If you checked this block and you are less than 62 years of age: you should submit the following documents:

Remember, you must notify your PHA if a household member dies or moves out. You must also obtain the PHA's approval to allow additional family members or friends to move in your home prior to them moving in.

What are the penalties for providing false information?

Knowingly providing false, inaccurate, or incomplete information is FRAUD and a CRIME. If you commit fraud, you and your family may be subject to any of the following penalties:
1. Eviction
2. Termination of assistance
3. Repayment of rent that you should have paid had you reported your income correctly
4. Prohibited from receiving future rental assistance for a period of up to 10 years
5. Prosecution by the local, state, or Federal prosecutor, which may result in you being fined up to $10,000 and/or serving time in jail.
Protect yourself by following HUD reporting requirements. When completing applications and reexaminations, you must include all sources of income you or any member of your household receives.

If you have any questions on whether money received should be counted as income or how your rent is determined, ask your PHA. When changes occur in your household income, contact your PHA immediately to determine if this will affect your rental assistance.

What do I do if the EIV information is incorrect?
Sometimes the source of EIV information may make an error when submitting or reporting information about you. If you do not agree with the EIV information, let your PHA know.

If necessary, your PHA will contact the source of the information directly to verify disputed income information. Below are the procedures you and the PHA should follow regarding incorrect EIV information.

Debts owed to PHAs and termination information reported in EIV originates from the PHA who provided you assistance in the past. If you dispute this information, contact your former PHA directly in writing to dispute this information and provide any documentation that supports your dispute. If the PHA determines that the disputed information is incorrect, the PHA will update or delete the record from EIV.

Employment and wage information reported in EIV originates from · the employer. If you dispute this information, contact the employer in writing to dispute and request correction of the disputed employment and/or wage information. Provide your PHA with a copy of the letter that you sent to the employer. ff you are unable to get the employer to correct the information, you should contact the SWA for assistance.

Unemployment benefit information reported in EIV originates from the SWA. If you dispute this information, contact the SWA in writing to dispute and request correction of the disputed unemployment benefit information. Provide your PHA with a copy of the letter that you sent to the SWA.

Death, SS and SSI benefit information reported in EIV originates from the SSA. If you dispute this information, contact the SSA at (800) 772-1213, or visit their website at: www.socialsecurity.gov. You may need to visit your local SSA office to have disputed death information corrected.

Additional Verification. The PHA, with your consent, may submit a third party verification form to the provider ( or reporter) of your income for completion and submission to the PHA.

You may also provide the PHA with third party documents (i.e. pay stubs, benefit award letters, bank statements, etc.} which you may have in your possession.

Identity Theft. Unknown EIV information to you can be a sign of identity theft. Sometimes someone else may use your SSN, either on purpose or by accident. So, if you suspect someone is using your SSN, you should check your Social Security records to ensure your income is calculated correctly (call SSA at (800) 772-1213); file an identity theft complaint with your local police department or the Federal Trade Commission ( call FTC at (877) 438-4338, or you may visit their website at: http://www.flc.gov). Provide your PHA with a copy of your identity theft complaint.

Where can I obtain more information on EIV and the income verification process?
Your PHA can provide you with additional information on EIV and the income verification process. You may also read more about EIV and the income verification process on HUD's Public and Indian Housing EIV web pages at:

The information in this Guide pertains to applicants and participants (tenants) of the following HUD-PIH rental assistance programs:
1. Public Housing (24 CFR 960}; and
2. Section 8 Housing Choice Voucher (HCV),(24 CFR 982); and
3. Section 8 Moderate Rehabilitation (24 CFR 882); and
4. Project-Based Voucher (24 CFR 983)
My signature below is confirmation that I have received this Guide.
Signature

Clear
Date

MonthDayYear

U.S. Department of Housing and Urban Development
Office of Public and Indian Housing (PIH)

What You Should Know about EIV

A Guide for Applicants & Tenants of Public Housing & Section 8 Programs

What is EIV?

The web-based Enterprise computer Income Verification system (EIV) that system contains employment and income information of individuals
who participate in HUD rental assistance programs. All Public Housing Age (PHAs) are required to use HUD's EIV system.

What information is in EIV and where does it come from?
HUD PHA, the obtains Social information Security about Administration you from (SSA), your localand U.S. (HHS).

HHS provides HUD with wage and employment information unemployment as compensation reported by information employers; as reportedand by the State Workforce Agency (SWA).

SSA provides HUD with death, Social Security (SS) and Supplemental Security Income (SSI) information.

What is the EIV information used for?
Primarily, the t agents information hired by is PHAs) used for by the PHAs following(and purposes management to:
1. Confirm your name, date of birth (DOB), and Social Security Number (SSN) with SSA.
2. Verify your reported income sources and amounts.
3. Confirm your participation in only one HUD rental assistance program.
4. Confirm if you owe an outstanding debt to PHA.
5. Confirm any negative status if you moved out of a subsidized unit (in the past) under the Public Housing or Section 8 program.
6. Follow up with you, other adult household members, or your listed emergency contact regarding deceased household members.
EIV household will alert has your used PHA a if false you SSN, or failed anyone to in report your is complete receiving and rental accurate assistance income at information, another or address. Remember, you may receive rental assistance at only one home!

EIV will also alert PHAs if you owe an outstanding debt to negative any PHA status (in any when state you or U.S. voluntarily or territory) and involuntarily any moved Housing out or of Section a 8 subsidized program. This unit under information the is Publicused to time of determine application. your eligibility for rental assistance at the time of application.

The information in EIV is also used by HUD, HUD's Office ensure of that your Inspector family General and PHAs (OIG), comply and with auditors to ensure that your family and PHAs comply with HUD rules.

Overall, the purpose of EIV is to identify and prevent fraud within HUD rental assistance programs, so that limited taxpayer's dollars can assist as many eligible families as possible. EIV will help to improve the integrity of HUD rental assistance programs.

Is my consent required in order for information to be obtained about me?

Yes, your consent is required in order for HUD or the PHA to obtain information about you. By law, you are required to sign one or more consent forms. When you sign a form HUD-9886 (Federal Privacy Act Notice and Authorization for Release of Information) or a PHA consent form (which meets HUD standards), you are giving HUD and the PHA your consent for them to obtain information about you for the purpose of determining your eligibility and amount of rental assistance. The information collected about you will be used only to determine your eligibility for the program, unless you consent in writing to authorize additional uses of the information by the PHA.

Note: If you or any of your adult household members refuse to sign a consent form, your request for initial or continued rental assistance may be denied. You may also be terminated from the HUD rental assistance program.

What are my responsibilities?
As a tenant (participant) of a HUD rental assistance program, you and each adult household member must disclose complete and accurate information to the PHA, including full name, SSN, and DOB; income information; and ceritify that your reported household compositions (houehold members), income, and expense information is true to the best of your knowledge.

Who will have access to the information collected?
This information will be available to HUD employees, PHA employees, and contractors of HUD and PHAs.

How will this information be used?
PHAs will have access to this information during the time of application for rental assistance and reexamination of family income and composition for existing participants. PHAs will be able to access this information to determine a family's suitability for initial or continued rental assistance, and avoid providing limited Federal housing assistance to families who have previously been unable to comply with HUD program requirements. If the reported information is accurate, a PHA may terminate your current rental assistance and deny your future request for HUD rental assistance, subject to PHA policy.

How long is the debt owed and termination information maintained in EIV?
Debt owed and termination information will be maintained in EIV for a period of up to ten (10) years from the end of participation date or such other period consistent with State Law.

What are my rights?
In accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to its implementation of the Federal Privacy Act of 1974 (24 CFR Part 16), you have the following rights:
1. To have access to your records maintained by HUD, subject to 24 CFR Part 16.
2. To have an administrative review of HUD's initial denial of your request to have access to your records maintained by HUD.
3. To have incorrect information in your record corrected upon written request.
4. To file an appeal request of an initial adverse determination on correction or amendment of record request within 30 calendar days after the issuance of the written denial.
5. To have your record disclosed to a third party upon receipt of your written and signed request.
What do I do if I dispute the debt or termination information reported about me?
If you disagree with the reported information, you should contact in writing the PHA who has reported this information about you. The PHA's name, address, and telephone numbers are listed on the Debts Owed and Termination Report.
You have a right to request and obtain a copy of this report from the PHA. Inform the PHA why you dispute the information and provide any documentation that supports your dispute. HUD's record retention policies at 24 CFR Part 908 and 24 CFR Part 982 provide that the PHA may destroy your records three years from the date your participation in the program ends. To ensure the availability of your records, disputes of the original debt or termination information must be made within three years from the end of participation date; otherwise, the debt and termination information will be presumed correct. Only the PHA who reported the adverse information about you can delete or correct your record.
Your filing of bankruptcy will not result in the removal of debt owed or termination information from HUD's EIV system. However, if you have included this debt in your bankruptcy filing and/or this debt has been discharged by the
bankruptcy court, your record will be updated to include the bankruptcy indicator, when you provide the PHA with documentation of your bankruptcy status.
The PHA will notify you in writing of its action regarding your dispute within 30 days of receiving your written dispute. If the PHA determines that the disputed information is incorrect, the PHA will update or delete the record. If the PHA determines that the disputed information is correct, the PHA will provide an explanation as to why the information is correct.

This notice was provided by the below-listed PHA:

Warren Housing Authority
801 West Central Street
Warren, AR 71761
Phone: 870.226.2600
Email: warrenha@sbcglobal.net

I hereby acknowledge that the PHA provided me with the Debts Owed to PHAs & Termination Notice:
Signature

Clear
Date

MonthDayYear

U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS

Paperwork Reduction Notice: Public reporting burden for this collection of information is estimated to average 7 minutes per response. This includes the time for respondents to read the document and certify, and any recordkeeping burden. This information will be used in the processing of a tenancy. Response to this request for information is required to receive benefits. The agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid 0MB control number. The 0MB Number is 2577-0266, and expires 10/31/2019.

NOTICE TO APPLICANTS AND PARTICIPANTS OF THE FOLLOWING HUD RENTAL ASSISTANCE PROGRAMS:
- Public Housing (24 CFR 960)
- Section 8 Housing Choice Voucher, including the Disaster Housing Assistance Program (24 CFR 982)
- Section 8 Moderate Rehabilitation (24 CFR 882)
- Project-Based Voucher (24 CFR 983}
The U.S. Department of Housing and Urban Development maintains a national repository of debts owed to Public Housing Agencies (PHAs} or Section 8 landlords and adverse information of former participants who have voluntarily or involuntarily terminated participation in one of the above-listed HUD rental assistance programs. This information is maintained within HUD's Enterprise Income Verification (EIV) system, which is used by Public Housing Agencies (PHAs} and their management agents to verify employment and income information of program participants, as well as, to reduce administrative and rental assistance payment errors. The EIV system is designed to assist PHAs and HUD in ensuring that families are eligible to participate in HUD rental assistance programs and determining the correct amount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUD regulations at 24 CFR 5.233.

HUD requires PHAs, which administers the above-listed rental housing programs, to report certain information·at the conclusion of your participation in a HUD rental assistance program. This notice provides you with information on what information the PHA is required to provide HUD, who will have access to this information, how this information is used and your rights. PHAs are required to provide this notice to all applicants and program participants and you are required to acknowledge receipt of this notice by signing page 2. Each adult household member must sign this form.

What information about you and your tenancy does HUD collect from the PHA?
The following information is collected about each member of your household (family composition): full name, date of birth, and Social Security Number.
The following adverse information is collected once your participation in the housing program has ended, whether you voluntarily or involuntarily move out of an assisted unit:
1. Amount of any balance you owe the PHA or Section 8 landlord (up to $500,000) and explanation for balance owed (i.e. unpaid rent, retroactive rent (due to unreported income and/ or change in family composition} or other charges such as damages, utility charges, etc.); and
2. Whether or not you have entered into a repayment agreement for the amount that you owe the PHA; and
3. Whether or not you have defaulted on a repayment agreement; and
4. Whether or not the PHA has obtained a judgment against you; and
5. Whether or not you have filed for bankruptcy; and
6. The negative reason(s) for your end of participation or any negative status (i.e., abandoned unit, fraud, lease violations, criminal activity, etc.) as of the end of participation date.

Arkansas Department of Human Services
CONSENT FOR RELEASE OF INFORMATION

This is your authority to release the requested: Income/Food Stamps Information
Information regarding First Name Last Name SSN to the Arkansas Department of Human Services or authorized representative listed below.
Signature of Applicant/Recipient or Authorized Representative and Title

Clear
Date

MonthDayYear
Bradley County

Obtain original signatures on all copies. Worker may sign as witness.

*Complete only if Request is for Medical information.

**Note: Client's medical records become part of the client's file and may be reviewed by the client upon request unless the treatment physician provides a written determination that disclosure of such information would be detrimental to the clients welfare (Re. Ark. Code Ann. 18-46-108).

If you need this material in a different format, such as large print, contact your OHS Office.

4571.3 and HOPE II Notice of Program

HUD Fact Sheet
Verification of Information Provided by
Applicants and Tenants of Assisted Housing

What Verification Involves
To receive housing assistance, applicants and tenants who are 18 years of Age and each family head, spouse, or co-head regardless of age must Provide the owner or management agent (O/A) or public housing agency (PHA) with certain information specified by the U.S. Department of Housing and Urban Development (HUD).

To make sure that the assistance is used properly, Federal laws require that the information you provide be verified. This information is verified in two ways:

1. HUD, 0/ As, and PHAs may verify the information you provide by hecking with the records kept by certain public agencies ( e.g. Social Security Administration (SSA), State agency that keeps wage and Unemployment compensation claim information, and the Department of Health and Human Services' (HHS) National Directory of New Hires (NDNH) database that stores wage, new hires, and unemployment Compensation). HUD (only) may verify information covered in your tax returns from the U.,S. Internal Revenue Service (IRS). You give your consent to the release of this information by signing form HUD-9887.
this form.

2. The O/A must verify the information that is used to determine your eligibility and the amount ofrent you pay. You give your consent to the release of this information by signing the form HUD-9887-A, tge fim GYD-9887-A, and the individual verification and consent forms that apply to you. Federal laws limit the kinds of information the 0/ A can receive about you. The amount of income you receive helps to determine the amount of rent you will pay. The 0/ A will verify all of the sources of income that you report. There are certain allowances that reduce the income used in determining tenant rents. Example: income used in determining tenant rents. Mrs. Anderson is 62 years old. Her age qualifies her for a medical allowance. Her annual income will be adjusted because of this allowance. Because Mrs. Anderson's medical expenses will help determine the amount of rent she pays, the owner is required to verify any medical expenses that she reports. Example: Mr. Harris does not qualify for the medical allowance because he is not at least 62 years of age and he is not handicapped or disabled. Because.he is not eligible for the medical allowance, the amount of his medical expenses does not change the amount of rent he pays. Therefore, the owner cannot ask Mr. Harris anything about his medical expenses and cannot verify with a third party about any medical expenses he has.

Customer Protections
Information received by HUD is protected by the Federal Privacy Act. Information received by the O/A or the PHA is subject to
State privacy laws. Employees of HUD, the O/A, the PHA
are subject to penalties for using these consent forms improperly.
You do not have to sign the form HUD-9887-A or the individual verification consent forms when they are given to you at your certification or recertification interview. You may take them home with you to read or to discuss with a third party of your choice. The 01 A will give you another date when you can return to sign these forms.
If you cannot read and/or sign a consent form due to a disability, the 0/ A shall make a reasonable accommodation in accordance with Section 504 of the Rehabilitation Act of 1973. Such accommodations may include: home visits when the applicant's or tenant's disability prevents him/her from coming to the office to complete the forms; the applicant or tenant authorizing another person to sign on his/her behalf; and for persons with visual impainnents, accommo-

If an adult member of your household, due to extenuating circumstances, is unable to sign the form HUD-9887 or the individual verification forms on time, the 0/ 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.

The 0/A must tell you, or a third party which you choose, of the findings made as a result of the O/A verifications authorized by your consent. The 0/ A must give you the opportunity to contest such findings in accordance with HUD Handbook 4350.3 Rev. 1. However, for infonnation received under the fonn HUD-9887, or
form HUD-9887-A, HUD, the O/A or the PHA, may inform you of these findings.

0/ As must keep tenant files in location that ensures confidentiality. Any employee of the 0/ A who fails to keep tenant information confidential is subject to the enforcement provisions of actions the State Privacy Act and is subject to enforcement actions by HUD. Also, any applicant or tenant affected by negligent disclosure or improper use of information may bring civil action for damages, and seek other relief as may be appropriate, against the employee.

HUD 9887-A requires the 0/A to give each household a copy of the Fact Sheet, and fonns HUD-9887, HUD-9887-A along with appropriate individual consent fonns. The package you will receive will include the following documents:
1. HUD 9887/A Fact Sheet: Describes the requirement to verify infonnation provided by individuals who apply for housing·assistance.
  This fact sheet also describes consumer protections under the verification process.
2. Form HUD-9887: Allows the release of information between government agencies.
3. Form HUD-9887-A: Describes the requirement of third party verification along with consumer protections
4. Individual verification consents: Used to verify the relevant infonnation provided by applicants/tenants to detennine their eligibility and level of benefits.
Consequences for Not Signing the Consent Forms
If you fail to sign the form HUD-9887,the form HUD-9887-A, or the individual verification forms, this may result in your assistance being denied (for applicants) or your assistance being terminated
(for tenants). See further explanation on the forms HUD-9887 and 9887-A.

If you are an applicant and are denied assistance for this reason, the Owner must notify you of the reason for your rejection and give you an opportunity to appeal the decision.

If you are a tenant and your assistance is terminated for this reason, the O/A must follow the procedures set out in the Lease. This includes the opportunity for you to meet with the O/A.

Programs Covered by this Fact Sheet

Rental Assistance Program (RAP)
Rent Supplement
Section 8 Housing Assistance Payments Programs ( administered by the Office of Housing)
Section 202
Sections 202 and 811 PRAC
Section 202/162 PAC
Section 221(d)(3) Below Market Interest Rate Section 236

Failure to Sign the Consent Form
Failure to sign any required consent form may result in the denial of assistance or termination of assisted housing benefits. If an applicant
is denied assistance for this reason, the Owner must follow the notification procedures in Handbook 4350.3 Rev. I. If a tenant is denied assistance for this reason, the O/A must follow the procedures set out
in 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 independently I) verified the information you have provided with respect to your eligibility and level of benefits and 2) with respect to income (including both earned and unearned income), the O/A has verified whether you have 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 of 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 verification 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). If this happens, the O/A 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.

The 0/ A shall inform you, or a third party which you designate,
of the findings made on the basis ofinformation verified under this consent and shall give you an opportunity to contest such findings in accordance with Handbook 4350.3 Rev. I.

The Owner must provide you with information obtained under this consent in accordance with State privacy laws.

If an adult member of the household, due to extenuating circumstances, is unable to sign the required forms on time, the 0/ 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.

Individual consents to the release of information expire 15 months after they are signed. The 0/ A may use these individual consent forms during the 120 days preceding the certification period. The Owner may also use these forms during the certification period, but only in cases where the 0/ A receives information indicating that the information you have provided may be incorrect. Other uses are prohibited. The 0/ A may not make inquiries into information that is older than 12 months unless he/she has received inconsistent information and has reason to believe that the information that you have supplied is incorrect. If this occurs, the 0/ A may obtain information within the last 5 years when you have received assistance.

I have read this information on the purposes and uses of information that is verified and/or it has been explained to me and consent to the release of information for these purposes and uses.
Name of Applicant or Tenant

First NameLast Name
Signature

Clear
Date

MonthDayYear
HUD, the O/A, the PHA and any Owner {or any employee of HUD, the O/A, or the PHA) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form.

Use of the information collected based on the form HUD 9887-A is restricted to the purposes cited on the form HUD 9887-A. Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or tenant may be subject to a misdemeanor and fined 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 officer or employee of HUD, the PHA or the Owner responsible for the unauthorized disclosure or improper use.

Applicant's/Tenant's Consent to the Release of Information
Verification By Owners of Information
Supplied by Individuals Who Apply For Housing Assistance

Instructions to Owners
1. Give the documents listed below to the applicants/tenants to sign.
Staple or clip them together in one package in the order listed.
a. The HUD-9887/A Fact Sheet.
b. Fonn HUD-9887.
c. Fonn HUD-9887-A.
d. Relevant verifications (HUD Handbook 4350.3 Rev. I).

2. Verbally inform applicants and tenants that
a. They may take these fonns home with them to read or to discuss
with a third party of their choice and to return to sign them on a
date they have worked out with you, and
b. If they have a disability that prevents them from reading and/or
signing any consent, that you, the Owner, are required to provide reasonable accommodations.

3. Owners are required to give each household a copy of the HUD 9887/A Fact Sheet, fonn HUD-9887, and form HUD-9887-A after obtaining the required applicants/tenants signature(s). Also, owners must give the applicants/tenants a copy of the signed individual verification forms
upon their request.

Instructions to Applicants and Tenants
This Fonn HUD-9887-A contains customer information and protections concerning the HUD-required verifications that Owners must perform.

1. Read this material which explains:
• HUD's requirements concerning the release of information,
and
• Other customer protections.
2. Sign on the last page that:
* you have read this form, or
* the Owner or a third party of your choice has explained it to you, and you consent to the release of information for the purposes and uses described.

Authority for Requiring Applicant's/Tenant's Consent to the Release of Information
Section 904 of the Stewart 8. McKinney Homeless Assistance Amendments Act of 1988, as amended by section 903 of the Housing and Community Development Act of 1992. This law is found at 42 U.S.C. 3544.

In part, this law requires you to sign a consent form authorizing the Owner to request current or previous employers to verify salary and
wage infonnation pertinent to your eligibility or level of benefits.

In addition, HUD regulations (24 CFR 5.659, Family Information and Verification) require as a condition of receiving housing assistance that you must sign a HUD-approved release and consent authorizing any depository or private source of income to furnish such information that is necessary in detennining your eligibility or level of benefits. This includes infonnation that you have provided which will affect the amount of rent you pay. The information includes income and assets, such as salary, welfare benefits, and interest earned on savings accounts. They also include certain adjustments to your income, such as the allowances for dependents and for households whose heads or spouses are elderly handicapped, or disabled; and allowances for child care expenses, medical expenses, and handicap assistance expenses.

Purpose of Requiring Consent to the Release of lnformation
In signing this consent form, you are authorizing the Owner of the housing project to which you are applying for assistance to request information from a third party about you. HUD requires the housing owner to verify all of the information you provide that affect your eligibility and level of benefits to ensure that you are eligible for assisted housing benefits and that these benefits are set at the correct levels. Upon the request of the HUD office or the PHA (as Contract Administrator) the housing Owner may provide HUD or the PHA with the information you have submitted and the information the Owner receives under this consent.

Uses of Information to be Obtained
The individual listed on the verification form may request and receive the information requested by the verification, subject to the limitations of this form. HUD is required to protect the income information it obtains in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. The PHA and the Owner are also required to protect the income infonnation they obtain in accordance with any applicable state privacy law. Should the Owner receive information from a third party that is inconsistent with the information you have provided, the Owner is required to notify you in writing identifying the information believed to be incorrect. If this should occur, you will have the opportunity to meet with the Owner to discuss any discrepancies.

Who Must Sign the Consent Form
Each member of your household who is 18 years of age or older must sign the relevant consent forms at the initial certification, at each recertification and at each interim certification, if applicable. In addition, when new adult members join the household and when members of the household become 18 years of age they must also sign the relevant consent forms.
Persons who apply for or receive assistance under the following programs must sign the relevant consent forms:
Rental Assistance Program (RAP)
Rent Supplement
Section 8 Housing Assistance Payments Programs (administered by the Office of Housing)
Section 202
Sections 202 and 811 PRAC
Section 202/162 PAC
Section 221(d)(3) Below Market Interest Rate
Section 236
HOPE 2 Home Ownership of Multifamily Units
Agencies To Provide Information
State Wage Infonnation Collection Agencies. HUD and PHA). This consent is limited to wages and unemployment compensation you have received during period(s) within the last 5 years when you have received assisted housing benefits.

U.S. Social Security Administration (HUD only). This consent is limited to the wage and self employment information from your current fonn W-2.

National Directory of New Hires contained in the Department of Health and Human Services' system of records. This consent is limited to wages and unemployment compensation you have received during period(s) within the last 5 years when you have received assisted housing benefits.

U.S. Internal Revenue Service (HUD only). This consent is limited to infonnation covered in your current tax return.

This consent is limited to the following information that may appear on your current tax return:

1099-S Statement for Recipients of Proceeds from Real Estate Transactions

1099-B Statement for Recipients of Proceeds from Real Estate Brokers and Barters Exchange Transactions
I 099-A Information Return for Acquisition or Abandonment of Secured Property
I 099-G Statement for Recipients of Certain Government Payments
I 099-DIV Statement for Recipients of Dividends and Distributions
1099 INT Statement for Recipients of Interest Income
I 099-MISC Statement for Recipients of Miscellaneous Income
I 099-OID Statement for Recipients of Original Issue Discount
1099-PATR Statement for Recipients of Taxable Distributions Received from Cooperatives
1099-R Statement for Recipients of Retirement Plans
W2-G Statement of Gambling Winnings1065-Kl Partners Share of Income, Credits, Deductions, etc. 104-1 Kl Beneficiary's Share oflncome, Credits, Deductions, etc. 1120S-KI Shareholder's Share of Undistributed Taxable Income, Credits, Deductions, etc.

I understand that income information obtained from these sources
will be used to verify information that I provide in determining initial
or continued eligibility for assisted housing programs and the level
of benefits.

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 HUD Office, Office of
Inspector General (OIG) or the PHA (whichever is applicable) and
the O/A have independently verified: I) the amount of the income, wages, or unemployment compensation involved, 2) whether you actually have ( or had) access to such income, wages, or benefits for your own use, and 3) the period or periods when, or with respect to which you actually received such income, wages, or benefits. A photocopy of the signed consent may be used to request a third party to verify any information received under this consent (e.g., employer).

HUD, the O/A, or the PHA or the owner 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. 1.

If a member of the household who is required to sign the consent
form is unable to sign the form on time due to extenuating circumstances, the 0/ 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.

This consent form expires 15 months after signed.
Privacy Act Statement. The Department of Housing and Urban Development (HUD) is authorized to coiled this information by the U.S. Housing Act of 1937, as amended (42 U.S.C. 1437 et. seq.); the Housing and Urban-rural Recovery Act of 1983 (P.L. 98-181); the Housing and Community Development Technical Amendments of 1984 (P.L. 98-479); and by the Housing and Community Development Act of 1987 (42 U.S.C. 3543). The information is being collected by HUD to determine an applicant's eligibility, the recommended unit size, and the amount the tenant(s) must pay toward rent and utilities. HUD uses this information to assist in managing certain HUD properties, to protect the Government's financial interest, and to verify the accuracy of the information furnished. HUD, the owner or management (O/A), or a Public Housing Authority (PHA) may conduct a computer match to verify the information you provide. This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatory investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. You must provide all of the information requested. Failure to provide any information may result in a delay or rejection of your eligibility approval.

Penalties for Misusing this Consent:

HUD, the O/A, and any PHA (or any employee of HUD, the OJA, or the PHA) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form.
Use of the information collected based on the form HUD 9887 is restricted to the purposes cited on the form HUD 9887. Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or tenant may be subject to a misdemeanor and fined 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 officer or employee of HUD, the Owner or the PHA responsible for the unauthorized disclosure or improper use.
Consent: I consent to allow HUD, the 0/A, or the PHA to request and obtain income information from the federal and state agencies listed on the back of this form for the purpose of verifying my eligibility and level of benefits under HUD's assisted housing programs.
Head of Household

Clear
Date

MonthDayYear
Spouse

Clear
Date

MonthDayYear
Other Family Member over age 18

Clear
Date

MonthDayYear
Other Family Member over age 18

Clear
MonthDayYear
Other Family Member over age 18

Clear
Date

MonthDayYear
Other Family Member over age 18

Clear
Date

MonthDayYear
Other Family Member over age 18

Clear
Date

MonthDayYear
Other Family Member over age 18

Clear
Date

MonthDayYear
Clear
Date

MonthDayYear

Notice and Consent for the Release of Information
to the U.S. Department of Housing and Urban Development(HUD) and to an Owner and Management Agent (O/A), and to a Public Housing Agency (PHA)

U.S. Department of Housing and Urban Development Office of Housing
Head of Household

Clear
Date

MonthDayYear
Social Security Number(if any of Head of Household)
Spouse

Clear
Date

MonthDayYear
Other Family Member over age 18

Clear
Date

MonthDayYear
Other Family Member over age 18

Clear
Date

MonthDayYear
Other Family Member over age 18

Clear
Date

MonthDayYear
Other Family Member over age 18

Clear
Date

MonthDayYear
Other Family Member over age 18

Clear
Date

MonthDayYear
Other Family Member over age 18

Clear
Date

MonthDayYear
Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 ( 42 U.S.C. 2000d), and the fair Housing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and participants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and other information are being collected by HUD to determine your eligibility, the appropriate bedroom size and the amount your family will pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoring HUD-assisted housing programs, to protect the Government's financial interest, and to verify the accuracy of the information you provide. This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatory investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. Penalty: You must provide all of the information requested by the HA, including all Social Security Numbers you, and all other household members age six years and older, have and use. Giving the Social Security Numbers of all household members six years of age and older is mandatory, and not providing the Social Security Numbers will effect your eligibility. Failure to provide any of the requested information may result in a delay or rejection of your eligibility approval.

Penalties for Misusing this Consent:
Hud, the HA and any owner (or any employee of HUD, the HA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form.

Use of the information collected based on the form HUD 9886 is restricted to the purpose cited on the form HUD 9886. Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000.

Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use.

Authorization for the Release of Information Privacy Act Notice
to the U.S. Department of Housing and Urban Development(HUD) and the Housing Agency/Authority(HA)

Authority: Section 904 of the Stewart B. McKinney Homeless Assistance Amendments act of 1988, as amended by Section 903 of the Housing and Community Development Act of 1992 and Section 3003 of the Omnibus Budget Reconciliation Act of 1993. This law is found at 42 U.S.C. 3544.

This law requires that you sign a consent form authorizing: ( 1) HUD and the Housing Agency/ Authority (HA) to request verification of salary and wages from current or previous employers;(2) HUD and the HA to request wage and unemployment compensation claim information from the state agency responsible for keeping that information; (3) HUD to request certain tax return information from the U.S. Social Security Administration and the U.S. Internal Revenue Service. The law also requires independent verification of income information. Therefore, HUD or the HA may request information from financial institutions to verify your eligibility and level of benefits.

Purpose: In signing this consent form, you are authorizing HUD and the above-named HA to request income information from the sources listed on the form. HUD and the HA need this information to verify your household's income, in order to ensure that you are eligible for assisted housing benefits and that these benefits are set at the correct level. HUD and the HA may participate in computer matching programs with these sources in order to verify your eligibility and level of benefits.

Uses of Information to be Obtained: HUD is required to protect the income information it obtains in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. HUD may disclose information
(other than tax return information) for certain routine uses, such as to the other government agencies for law enforcement purposes, to Federal agencies for employment suitability purposes and to HAs for the purpose of determining housing assistance. The HA is also required to protect the income information it obtains in accordance with any applicable State privacy law. HUD and HA employees may be subject to penalties for unauthorized disclosures or improper uses of the income information that is obtained based on the consent form. Private owners may not request or receive information authorized by this form.

Who Must Sign the Consent Form: Each member of your household who is 18 years of age or older must sign the consent fonn. Additional signatures must be obtained from new adult members joining the household or whenever members of the household become 18 years of age.

Persons who apply for or receive assistance under the following programs are required to sign this consent form:

PHA-owned rental public housing Turnkey III Homeownership Opportunities Mutual Help Homeownership Opportunity Section 23 and 19( c) leased housing Section 23 Housing Assistance Payments HA-owned rental Indian housing
Section 8 Rental Certification
Section 8 Rental Voucher
Section 8 Moderate Rehabilitation

Failure to sign Consent Form: Your failure to sign the consent form may result in the denial of eligibility or termination of assisted housing benefits, or both. Denial of eligibility or termination of benefits is subject to the HA's grievance procedures and Section 8 informal hearing procedures.

Sources of Information To Be Obtained

State Wage Information Collection Agencies. (This consent is limited to wages and unemployment compensation I have received during period(s) within the last 5 years when I have received assisted housing benefits.)

U.S. Social Security Administration(HUD only) (This consent is limited to wage and self employment information and pay-
ments of retirement income as referenced at Section 6103(1)(7)(A) of the Internal Revenue Code.)

U.S. Internal Revenue Service (HUD only) (This consent is limited to unearned income [i.e., interest and dividends].)

Information may also be obtained directly from: (a) current and former employers concerning salary and wages and (b) financial institutions concerning unearned income (i.e., interest and dividends). I understand that income information obtained from these sources will be used to verify information that I provide in determining eligibility for assisted housing programs and the level of benefits. Therefore, this consent form only authorizes release directly from employers and financial institutions of information regarding any period(s) within the last 5 years when I have received assisted housing benefits.

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 must 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.

Any increase in income, such as wages from a new Job or an expected pay raise or bonus.

All assets, such as bank accounts, savings bonds, certificates of deposit, stocks, real estate, etc., that are owned by you or any member of your household.

All income from assets, such as interest from savings and checking accounts, stock dividends, etc.

Any business or asset (your home) that you sold in the last two years at less than full value.

The names of everyone, adults or children, relatives and non-relatives, who are living with you and make up your household. (Important Notice for Hurricane Katrina and Hurricane Rita

Evacuees: HUD's reporting requirements may be temporarily waived or suspended because of your circumstances. Contact the local housing agency before you complete the housing assistance application.)

Ask Questions
If you don't understand something on the application or recertification forms, always ask questions. It's better to be safe than sorry.

Watch Out for Housing Assistance Scams!
- Don't pay money to have someone fill out housing assistance application and recertification forms for you.
- Don't pay money to move up on a waiting 11st
- Don't pay for anything that is not covered by your lease.
- Get a receipt for any money you pay
- Get a written explanation if you are required to pay for anything other than rent (maintenance or utility charges).
Report Fraud
If you know of anyone who provided false information on a HUD housing assistance application or recertification or if anyone tells you to provide false information, report that person to the HUD Office of Inspector General Hotline. You can call the Hotline toll-free Monday through Friday, from 10:00 a.m. to 4:30 p.m., Eastern Time, at 1-800-347-3735. You can fax information to (202) 708-4829 or e-mail it to Hotline@hudoig.gov. You can write the Hotline at:

HUD OIG Hotline, GFI, 451 7th Street, SW Washington, DC 20410

APPLYING FOR HUD HOUSING ASSISTANCE?

THINK ABOUT THIS .. .IS FRAUD WORTH IT? Do You Realize ...

If you commit fraud to obtain assisted housing from HUD, you could be:
- Evicted from your apartment or house.
- Required to repay all overpaid rental assistance you received.
- Fined up to $10,000.
- Imprisoned for up to five years.
- Prohibited 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 recertification forms will be checked. The local housing agency, HUD, or the Office of Inspector General will check the income and asset information you provide with other Federal, State, or local governments and with private agencies. Certifying false information is fraud.

Documation to provide at the timeof your interview (all documents must be original documents & income statement must be dated within the last 90 days of the time of your interview):
1. Birth Certificate or Verification of Birth or Baptismal Certificate, Military Discharge papers, valie passport, census document showing age Naturalization certificate or Social Security Administration Benefits printout for entire houshold
2. Social Security Card or Other good forms of documentation for SSN: Original document issued by a federal or state government agency which contains the name, SSN, and other identifying information of the inidividual, Driver's license with SSN, Identification card issued by a medical insurance provider, or by an employer or trade union. Earnings statements on payroll stubs, Bank statement, Form 1099, Benefit award letter, Retirement benefit letter or Life insurance policy or Court records for entire houshold.
3. Proof of household income (check stub, employer statement, etc.) for entire household.
4. Photo ID (drver's license or I.D. card) for any person 18 yrs. or older listed on application.
Name

First NameLast Name
Date

MonthDayYear
Time

Hour Minutes

AM/PM Option
IT IS VERY IMPORTANT THAT YOU FURNISH ALL OF THE ABOVE INFORMATION SO THAT YOUR APPLICATION MAY BE PROCESSED. IF YOU CAN NOT KEEP THIS APPOINTMENT, PLEASE CALL THE OFFICE AT (870)-226-2600

Warren Housing Authority does not discriminate against persons with disabilities.
Notification: Section 504 prohibits discrimination on the basis of disability in any program, service, or activity that receives federal financial assistance. A person with disabilities may not be denied the opportunity to participate in a program, service, or activity; may not be required to accept a different kind or lesser program or service than what is provided to others, and may not be required to participate in separate programs and services, even if separate programs and services exist. A housing provider may not deny or refuse to sell or rent to a person with a disability, and may not impose application or qualification criteria, rental fees or sales prices, and rental or sales terms or conditions that are different than those required of or provided to persons who are not disabled. Housing providers may not require persons with disabilities to live only on certain floors, or to all live in one section of the housing. Housing providers may not refuse to make repairs, and may not limit or deny someone with a disability access to recreational and other public and common use facilities, parking privileges, cleaning or janitorial services, or any services which are made available to other residents. People with disabilities may not be denied the opportunity to serve on planning or advisory boards because their disabilities. Upon request, Warren Housing Authority will provide reasonable accommodations to people with disabilities so they can participate in WHA programs
Should be Empty:

	License Number	State Issued	Make/Model/Year
1.
2.

	Name	Employer	Total Weekly Wages	AFDC	Child Support	Social Security Benefits	Any Other Income
Household Member
Household Member
Household Member
Household Member
Household Member
Household Member

	Landlord's Name/Address	Your Address	Own/Rent	Dates (from-To)
1.
2.
3.
4.
5.

	Name (Last, First, MI)	Marital Status (M, D, S, DD)	Sex (F, M, DD)	Birth Date (mm/dd/yy)	Veteran (Y/N)	Student (Y/N)	SSN
1.
2.
3.
4.
5.
6.
7.
8.