GPHA Contributions Affidavit

Great Plains Housing Authority

Contribution Affidavit
Serving Dickey, Eddy, Foster, Logan, Sargent, Stutsman, and Wells Counties
CONTRIBUTIONS AFFIDAVIT
A contributor is a person who donates/gives money to another individual in order to help them pay their expenses. Federal Laws state that a person is subject to fine and/or imprisonment for making false statements to obtain federal housing assistance.

The Housing Authority requires that the following all questions must be answered. If a question does not apply, leave the space blank. If uncertain, use best available information. Person completing this form must sign and date it for submission.
Client's First and Last Name*
last 4 SSN*
Client Birth Date*

MonthDayYear
Date
Address*

Address

Street Address Line 2

City State ZipState / Province

Postal / Zip Code
Phone*
Email*
example@example.com
Contributor's Name (if none, put N/A)*
Contributor's Phone*
Contributor Address , city state Zip*
Choose the appropriate Statement:*

1. Contributor is not assisting household with any assistance2. Contributor is assisting with household bills3. Contributor is providing money to me
How are you receiving the contribution*
I am not currently and do not anticipate receiving any compensation from my contributor during the next 12 months. next 12 months.I am currently receiving or anticipate receiving financial support from the contributor during the next 12 months each month in the amount of
Client Signature*

Clear
Client Name*

First NameLast Name
Date Signed*

MonthDayYear
Date
Mailing address: 300 2nd Ave NE - Suite 200, Jamestown, ND 58401 Toll free: 800-340-4537 Web: www.greatplainsha.com Phone: 701-252-1098Email: office@greatplainsha.com

Locations: Carrington, Ellendale, Jamestown, New Rockford
Should be Empty:

Great Plains Housing Authority

CONTRIBUTIONS AFFIDAVIT