MAGNOLIA HOUSING AUTHORITY

INSTRUCTIONS:

This application must be filled out correctly and completely. You must use this application to apply for three of the five housing programs that Magnolia Housing Authority has to offer. If you have questions or need any assistance in completing this application, please feel free to contact our office. Any of our staff would be glad to assist you.

We MUST have a current address on file for you at all times. If you are homeless, please list an address of someone who can get your mail to you. Also, you must notify the housing authority, in writing, if your address changes after you have submitted your application. If we try to contact you and the letter is returned by the Post Office, your name will be removed from the waiting list - NO EXCEPTIONS. Please include addresses and phone numbers in all spaces that are indicated; if you do not know the phone number or address, please look them up. This is especially important on your landlord references. Please make sure to sign all areas that require a signature and date the application.

***Please include: Picture ID for members 18 and older, verification of Social Security numbers for household members (with some exceptions) ,birth certificates or other valid verification with proof of age such as; (Baptismal Cert., military Discharge papers, Valid passport, Census document Naturalization Certificate) for all household members and other documents and verification if they apply to your household which includes proof of income for all household members: (last six check stubs, current award letter, food stamp verification), all medical bills paid out of pocket, checking account bank statements for the last 6 months, and a savings account bank statements for the current month.

If you submit an application and do not fulfill all the above requirements, your application will be considered incomplete. Although Incomplete applications are accepted and applicants are added to the wait list with some specifications, it is your responsibility to ensure that the Magnolia Housing Authority receives all required information.

The Magnolia Housing Authority does not discriminate on the basis of disability status in the admission or access to, or treatment or employment in, its federally assisted programs and activities. Janice Hutcheson has been designated to coordinate compliance with the non-discrimination requirements contained in the Dept. of Housing and Urban Development's regulations implementing Section 504 (24CFR, part 8, dated June 2, 1988)

If you are disabled or have difficulty understanding English, please request our assistance and we ensure that you are provided with meaningful access based on your individual needs.

Si está discapacitado o tiene dificultades para comprender el inglés, solicite nuestra ayuda y nos aseguraremos de que se le proporcione un acceso significativo en función de sus necesidades individuales.

Si vous êtes handicapé ou avez des difficultés à comprendre l'anglais, veuillez demander notre assistance et nous nous assurerons que vous disposez d'un accès significatif en fonction de vos besoins individuels.

Haddii aad naafo tahay ama ay kugu adag tahay fahmidda Ingiriisiga, fadlan codso kaalmadeena waxaanan hubineynaa in lagu siiyay helitaan macno leh oo ku saleysan baahidaada shaqsiyeed.

'Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposed cited above. Any person who knowingly or willingly 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 or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security act at 208 (a) (6), (7) and (8 Violation of these provisions are cited as violations of 42 U.S.C 408 (a) (6), (7) and (8)

**Please note if your address changes you must notify PHA in writing. If we contact you by mail and our mail is returned your name will be dropped from the waiting list.

The Magnolia Housing Authority is an equal Housing Opportunity Provider

'Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposed cited above. Any person who knowingly or willingly 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 bringcivil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security act at 208 (a) (6), (7) and (8 Violation of these provisions are cited as violations of 42 U.S.C 408 (a) (6), (7) and (8

Family Composition: List all person (s) who will be residing with you.

*Include yourself. Please note the following codes for race:

W - White

B - Black

A - American Indian/Alaskan Native

A/P - Asian or Pacific Islander

Please note the following codes for ethnicity:

H - Hispanic

N/H - Non-Hispanic

'Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposed cited above. Any person who knowingly or willingly 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 or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security act at 208 (a) (6), (7) and (8 Violation of these provisions are cited as violations of 42 U.S.C 408 (a) (6), (7) and (8 ,,

HOUSEHOLD INCOME

Total Family Income: List all sources of income—earned, unearned, and gifts.

Includes the following: Food Stamps, TEA, Child Support, Social Security (SS), Supplemental Security Income (SSI), Pensions, Unemployment Benefits, Employment Wages, Families First, Contributions, and any lump sum of funds.

If you receive SSI or Social Security, you must provide proof by submitting your proof of income letter with your application.

If you are working, you must submit six (6) consecutive months of check stubs.

'Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposed cited above. Any person who knowingly or willingly 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 or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security act at 208 (a) (6), (7) and (8 Violation of these provisions are cited as violations of 42 U.S.C 408 (a) (6), (7) and (8).

'Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposed cited above. Any person who knowingly or willingly 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 or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security act at 208 (a) (6), (7) and (8 Violation of these provisions are cited as violations of 42 U.S.C 408 (a) (6), (7) and (8)

FOR COLLEGE STUDENTS ONLY

****If you are enrolled in college or have no future plans to do so, please mark a line through this page and proceed to the next page.

'Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements toany department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposed cited above. Any person who knowingly or willingly 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 or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security act at 208 (a) (6), (7) and (8 Violation of these provisions are cited as violations of 42 U.S.C 408 (a) (6), (7) and (8)

Please list your present and past landlords for the past five (5) years below. If you have had more than two (2) previous landlords in the past five (5) years, please list them on the back of this form. Failure to list at least three (3) landlords without an explanation could cause a delay or denial of housing. PRESENT LANDLORD: This is where you live now even if it's with your family/parents.

 

Federal rules and regulations state that we must try to assist applicants who quality for a preference before we can assist other applicants. By completing this application, it does not mean that all paperwork has been completed nor does it mean that all requirements have been met for assistance. I hereby certify the information I have provided in this application is true, correct, and complete to the best of my knowledge. That all information I have provided herein relative to family composition, income, and assets are correct as of the date and time of signing this form. I also realize that making a false statement or representation could make me subject to criminal prosecution. I hereby authorize the Magnolia Housing Authority to make inquiries from any source for the purpose of verifying the facts herein stated.

'Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposed cited above. Any person who knowingly or willingly 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 or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security act at 208 (a) (6), (7) and (8 Violation of these provisions are cited as violations of 42 U.S.C 408 (a) (6), (7) and (8

CONSENT

I authorize and direct any Federal, State, or local agency, organization, business or individual to release to the HOUING AUTHORITY OF THE CITY OF MAGNOLIA, ARKANSAS any information or materials needed to complete and verify my application for participation, and/or maintain my continued assistance under the Section8, Low-Income Public Housing, and/or other housing assistance programs. I understand and agree that this authorization or the information obtained with its use may be given to and used by the Department of Housing and Urban Development (HUD) in administration and enforcing program rules and policies.

I also consent for HUD or the PHA to release information from my file about my rental history to HUD, credit bureaus, collection agencies, or future landlords. This includes my rental payment history, and any violations of my lease or PHA policies.

INFORMATION COVERED

I understand that, depending on program policies and requirements, previous or current information regarding me or any household member may be needed. Verifications and inquiries that may be requested include, but are not limited to the following: Identity and Marital Status, Employment and Income Assets, Resident Rental Activity, Medical or Child Care Allowances, Credit and Criminal Activity, and Federal or State Assistance. I understand that this authorization cannot be used to obtain any information about me that is not pertinent to my eligibility for and continued participation in a housing assistance program.

GROUP OR INDIVIDUALS THAT MAY BE ASKED

The groups or individuals that may be asked to release the above information (depending on program requirements) include, but not limited to the following: Previous Landlords (including Public Housing Agencies), Courts and Post Offices, Social Security Administration, Medical and Child Care Providers, Banks/Other Financial Institutions, Past and Present Employers, Welfare Agencies, State Unemployment Agencies, Credit Providers/Credit Bureaus, Support and Alimony Providers, Veterans Administration, Retirement Status, Schools and Colleges, Law Enforcement Agencies, and Utility Companies.

COMPUTER MATCHING NOTICE AND CONSENT

I understand and agree that HUD per the Public Housing Authority may conduct computer matching program to verify the information supplied for my application or recertification. If a computer match is done, I understand that I have a right to notification of any adverse information found and a chance to disprove incorrect information. HUD or the PHA may be in agencies, including, but not limited to: State Employment Security Agencies, Department of Defense, Office of Personnel Management, the U.S. Postal Service, the Social Security Agency, and State Welfare and Food Stamp Agencies.

CONDITIONS

I agree that a photocopy or facsimile of this authorization may be used for the purposes stated above. The original of this authorization is on file with the PHA and will stay in effect for a year and one month from the date signed. I understand that I have a right to review my file and correct any information that I can prove is incorrect.

Note: This consent form may not be used to request a copy of an Income Tax Return. If a copy of an Income Tax Return is needed, IRS Form 4506, "Request for Copy of Tax Form" must be prepared and signed separately.

'Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposed cited above. Any person who knowingly or willingly 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 informationmay bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security act at 208 (a) (6), (7) and (8 Violation of these provisions are cited as violations of 42 U.S.C 408 (a) (6), (7) and (8

Giving True and Complete Information: I certify that all information provided on household composition, income, family assets and items for allowances and deductions, is accurate and complete to the best of my knowledge. I have reviewed the application form and the HUD Form 50058 or 50059, whichever applies to me, and certify that the information shown is true and correct.

Reporting Changes in Income or Household Composition: I know I am required to report immediately in writing within ten (10) days any changes in income and any changes in the household size, when a person moves in or out of the unit. I understand the rules regulating guests/visitors and when I must report anyone who is staying with me.

Reporting on Prior Housing Assistance: I certify that I have disclosed where I received previous Federal housing assistance and whether or not any money is owed. I certify that for this previous assistance I did not commit any fraud, knowingly misrepresent any information, or vacate the unit in violation of the lease.

No Duplicate Residence or Assistance: I certify that the house or apartment will be my principal residence that I will not obtain duplicate Federal Housing assistance while I am in the current program. I will not live anywhere else without notifying the Housing Authority immediately in writing. I will not sublease my assisted residence.

Cooperation: I know I am required to cooperate in supplying all information needed to determine my eligibility, level of benefits or to verify my true circumstances. Cooperation includes responding to requests from the housing office, attending pre-scheduled meetings, and completing and signing needed forms. | understand failure or refusal to do so may result in delays, termination of assistance, or eviction.

Criminal and Administrative Actions for False Information: I understand that knowingly supplying false, incomplete or inaccurate information is grounds for termination of housing assistance or termination of tenancy.

'Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected based on the consent form. Use of the information collected based on this verification form is restrictedto the purposed cited above. Any person who knowingly or willingly 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 or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security act at 208 (a) (6), (7) and (8 Violation of these provisions are cited as violations of U.S.C 408 (a) (6), (7) and (8

PURPOSE: Family income and other information is being collected by the Department of Housing and Urban Development (HUD) to determine an applicant's eligibility, the recommended unit size, and the amount the family must pay toward rent and utilities.

USE: HUD uses 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 furnished. HUD or a public housing agency/Indian housing authority may conduct a computer match to verify the information you provided. 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 public housing agency/Indian housing authority, including all social security numbers you, and all other household members age six (6) years and older is mandatory, and not providing the social security numbers will affect your eligibility. Failure to provide any of the requested information may result in a delay or rejection of your eligibility approval.

AUTHORITY FOR INFORMATION COLLECTION: The following laws authorize the collection of this information by HUD or the public housing agency/Indian housing authority: the U.S. Housing Act of 1937 (42 U.S.C., 1437 et seq, Title VI of the Civil Rights Acts of 1964, and Title VIII of the Civil Rights Act of 1968. The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and residents to submit the social security numbers of all household members at least six (6) years old.

'Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposed cited above. Any person who knowingly or willingly 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 or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security act at 208 (a) (6), (7) and (8 Violation of these provisions are cited as violations of 42 U.S.C 408 (a) (6), (7) and (8).

1.If any family violates any family obligations under the program.

2. Failing to repay a previous debt to a housing agency or owner.

3. Committing fraud in connection with any HUD program, or failing to disclose previously committed fraud in connection with any HUD program.

4.Providing false information on the application or at the time of re-evaluation.

5.Applicant/tenant non-cooperation during application interview or at rent redetermination.

6. Refusing or failing to complete the required forms or supply requested information.

7.If the family has engaged in or threatened abusive or violent behavior toward PHA personnel.

8.If any member of the family has ever been evicted from the public housing.

9.If a housing authority has terminated assistance under the certificate or voucher program.

10. If the housing authority has determined that any member of the family is illegally using a controlled substance.

11. If the housing authority has determined that any member of the family is abusing alcohol and interferes with health, safety, or right to peaceful enjoyment of the premises by other residents.

12. If any member of the household is an individual who is subject to a lifetime registration requirement under state sex offender registration program.

13. If any member of the family has ever been convicted of drug related or violent criminal activity.

14. If the applicant does not disclose and verity all social security numbers.

 

I am stating that I have read and understand the above Grounds for Denial or Termination of Assistance:

'Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposed cited above. Any person who knowingly or willingly 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 or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security act at 208 (a) (6), (7) and (8 Violation of these provisions are cited as violations of 42 U.S.C 408 (a) (6), (7) and (8 ,,

OMB Control # 2502-0581 Exp. (02/28/2019)

Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants

SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING

This form is to be provided to each applicant for federally assisted housing

Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require.

You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form.

 

Late payment of rent Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you.

Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law.

Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992) requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant's application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of 1975.

The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520 The public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers participating in HUD's assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name, address, telephone number, and other relevant information o fa family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any deliver, of services or special care to the tenant and assist with resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information. Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the collection displays a currently valid OMB control number.

Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN which, will be used by HUD to protect disbursement data ti'0111 fraudulent actions. Form HUD- 92006 (05/09)

This owner does not discriminate against persons with disabilities.

I have received notification of the Social Security disclosure and documentation requirements per Housing Notice 10-08.

'Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements toany department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposed cited above. Any person who knowingly or willingly 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 or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security act at 208 (a) (6), (7) and (8 Violation of these provisions are cited as violations of 42 U.S.C 408 (a) (6), (7) and (8)

Rural Development is an Equal Opportunity Lender, Provider, and Employer. Complaints of discrimination should be sent to USDA, Director, Office of Civil Rights, 1400 Independence Avenue S.W., Washington, D.C. 20250-9410 or call (800) 795-3272 or TDD (202) 720-6382

This owner does not discriminate against persons with disabilities.

 SECTION 214 CERTIFICATION OF RECEIPT

I have received a copy of the Notice of Section 214 Requirement for Applicant applying for and for tenants currently receiving 214 Housing Assistance.

'Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposed cited above. Any person who knowingly or willingly 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 or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security act at 208 (a) (6), (7) and (8 Violation of these provisions are cited as violations of 42 U.S.C 408 (a) (6), (7) and (8 ,

Rural Development is an Equal Opportunity Lender, Provider, and Employer. Complaints of discrimination should be sent to USDA, Director, Office of Civil Rights, 1400 Independence Avenue S.W., Washington, D.C. 20250-9410 or call (800) 795-3272 or TDD (202) 720-6382

As of November 1, 2013, Magnolia Housing Authority became a SMOKE FREE property. This means tenants are not allowed to smoke in their units or on MHA properties.

By signing below, you understand that we have a NO SMOKING policy. Failure to comply with this policy is immediate termination of your lease agreement.

EQUAL HOUSINGis OPPORTUNITY United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposed cited above. Any person who knowingly or willingly 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 or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security act at 208 (a) (6), (7) and (8 Violation of these provisions are cited as violations of 42 U.S.C 408 (a) (6), (7) and (8

'Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the

DISCLOSURE AND AUTHORIZATION FOR CONSUMER REPORTS

In connection with my application to rent a dwelling with MAGNOLIA HOUSING AUTHORITY further known as ("Company" I understand consumer reports will be requested by ACUTRAQ Background Screening. These reports may include, as allowed by law, the following types of information, as applicable: names and dates of current and previous employers, reason for termination of employment, work experience, names and dates of current and previous tenancy, reasons for termination of tenancy, credit, etc. I further understand that such reports may contain public record information such as, but not limited to: judgments, bankruptcy proceedings, evictions, criminal records, etc., from federal, state, and other agencies that maintain such records.

In addition, investigative consumer reports (gathered from personal interviews, as applicable, with current and former employers and/or landlords, past or current neighbors and associates of mine, etc to gather information regarding my work or tenant performance, character, general reputation and personal characteristics, and mode of living (lifestyle) may be obtained. I understand that the Company can use this disclosure and authorization to continue to obtain such consumer reports throughout my lease period.

Authorization: I hereby authorize procurement of consumer report(s) and/or investigative consumer report(s) by Company. This authorization shall remain on file and shall serve as ongoing authorization for the Company to procure such reports at any time during my lease period. I authorize without, reservation, any person, business or agency contacted by ACUTRAQ Background Screening, to furnish the above-mentioned information.

Summary of Rights: This authorization is conditioned upon the following representations of my rights: Iunderstand that I have the right to make a request to the consumer reporting agency: ACUTRAQ Background Screening P.O. Box 766 Elkins Arkansas, 479-439-9174 upon proper identification, to obtain copies of any reports furnished to the Company by ACUTRAQ Background Screening and to request the nature and substance of all information in its files on me at the time of my request, including the sources of information, and ACUTRAQ Background Screening, on Company's behalf, will provide a complete and accurate disclosure of the nature and scope of the investigation covered by any investigative consumer report(s ACUTRAQ Background Screening will also disclose the recipients of any such reports on me which the ACUTRAQ Background Screening has previously furnished within one year preceding my request (California three years I hereby consent to Company obtaining the above information from the ACUTRAQ Background Screening. I understand that I can dispute, at any time, any information that is inaccurate in any type of report with the ACUTRAQ Background Screening. I may view the ACUTRAQ Background Screening's privacy policy at their website: www.ACUTRAO.com I understand that if the Company is located in California, Minnesota or Oklahoma, that I have the right to request a copy of any report Company receives on me at the time the report is provided to Company. By checking the following box, I request a copy of all such reports be sent to me.

 

'Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposed cited above. Any person who knowingly or willingly 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 or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security act at 208 (a) (6), (7) and (8 Violation of these provisions are cited as violations of 42 U.S.C 408 (a) (6), (7) and (8