Things to Know

 

U.S. Department of Housing and Urban Development
Office of Inspector General
November 2004   
   
Things You
Should Know
 
   
Don't risk your chances for Federally assisted housing by providing false, incomplete, or inaccurate information on your application forms.
 

Purpose

This is to inform you that there is certain information you must provide when applying or assisted housing. There are penalties that apply if you knowingly omit information or give false information.

Penalties
for
Committing Fraud 

The United States Department of Housing and Urban Development (HUD) places a high
priority on preventing fraud. If your application or recertification forms contain false or
incomplete information, you may 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 5 years; and/or
? Prohibited from receiving future assistance. 

Your State and local governments may have other laws and penalties as well.

Asking
Questions 

When you meet with the person who is to fill out your application, you should know what is
expected of you. If you do not understand something, ask for clarification. That person can
answer your question or find out what the answer is.

Completing
The
Application 

When you answer application questions, you must include the following information:

Income 

? All sources of money you or any member of your household receive (wages. welfare 
payments, alimony, social security, pension, etc.):
? Any money you receive on behalf of your children (child support, social security for 
childr en, etc.);
? Income from assets (interest from a savings account, credit union, or certificate of 
deposit: dividends from stock, etc.);
? Earnings from second job or part time job;
? Any anticipated income (such as a bonus or pay raise you expect to receive) 

Assets

? All bank accounts, savings bonds, certificates of deposit, stocks, real estate, etc.. that
are owned by you and any adult member of your family's household who will be living
with you. 
Things to Know
  ? Any business or asset you sold in the last 2 years for less than its full value, such as your home to your children.
? The names of all of the people (adults and children ) who will actually be living with you, whether or not they are related to you.
   
Signing the
Application
? Do not sign any form unless you have read it, understand it, and are sure everything is complete and accurate.
? When you sign the application and certification for ms, you are claiming that they are complete to the best of your knowledge and belief. You are committing fraud if you sign a form knowing that it contains false or misleading information.
? Information you give on your application will be verified by your housing agency. In addition, HUD may do computer matches of the income you report with various Federal, State, or private agencies to verify that it is correct.
   
Recertifications You must provide updated in for mation at least once a year. Some programs require that you report any changes in income or family/household composition immediately. Be sure to ask when you must recertify. You must report on recertification for ms:
? All income changes, such as increases of pay and/or benefits, change or loss of job  and/or benefits, etc., for all household members.
? Any move in or out of a household member; and,
? All assets that you or your household members own and any assets that was sold in the last 2 years for less than its full value.
   
Beware of
Fraud
You should be aware of the following fraud schemes:
? Do not pay any money to file an application;
? Do not pay any money to move up on the waiting list;
? Do not pay for anything not covered by your lease;
? Get a receipt for any money you pay; and,
? Get a written explanation if you are required to pay for anything other than rent (such as maintenance charges).
   
Reporting
Abuse
If you are aware of anyone who has falsified an application, or if anyone tries to persuade you to make false statements, report them to the manager of your complex or your PHA. If that is not possible, then call the local HUD office or the HUD Office of Inspector General (OIG) Hotline at (800) 347- 3735. You can also write to:
HUD-OIGHOTLINE,(GFI) 451 Seventh Street, S.W., Washington, DC. 20410
   
   
  HUD- 1140-OIG THIS DOCUMENT MAY BE REPRODUCED WITHOUT PERMISSION
 
Cover Note
Housing Authority of the City of Morrilton

Phone: 501-354-2330

Fax 501-354-6641

TDD 501-354-9898

PO Box 229

Bridewell Manor

Morrilton AR 72110

 
In order to process your application the following items are required:
  1. Birth Certificates for everyone that will reside in the unit.
  2. Social Security Cards for everyone that will reside in the unit
  3. Photo ID, for every adult that will reside in the unit.
  4. Proof of all income from each family member that will reside in the unit

 

Your application will not be accepted without these items!
 
For Official Use Only!

This Certifies that Office Personnel have recieved all necessary documentation.

 

 

X______________________________(Office Personnel)

 

equal housing

For Official Use Only!

This Certifies that the Client has Produced all necessary documentation.

 

 

X____________________________________(Client)

 

General Info

Date:

Public Housing

Section 8

Time:

 

# Bedrooms:

HOUSING AUTHORITY OF MORRILTON, ARKANSAS

 

123 S Cherokee St, Morrilton, AR

 

Phone: (501) 354-2330

 

Personal Declaration

(Applicant)

INSTRUCTIONS:

YOU MUST COMPLETE THIS FORM AND BRING IT TO YOUR OFFICE APPOINTMENT. (Please Print or Type) THIS FORM MUST BE SIGNED BY ALL ADULTS AT THE OFFICE APPOINTMENT.

(Failure to complete this form will result in delays in processing your application and/or rescheduling your office appointment.)

The information you give regarding household composition, income, family assets and deductions must be accurate and complete to the best of your knowledge and belief.

APPLICANT FAMILY/UNIT:

Applicant Name

Address

Apt. #

City

State

Zip Code

Home #

Work #

Person to call in case of emergencies:

Name Of Friend/Relative

Address

Apt. #

City

State

Zip Code

Home #

Work #


A.HOUSEHOLD ADULT MEMBERS: (List children in Part B.)

List yourself and all other persons who are part of your application. In addition, list all other persons living/staying in the same residence with you. List all adults, age 18 and over in this section. Print clearly. This adults only.

1.

Last Name

First Name

MI

Soc. Sec. #

Birth Place/City, State

Birth Date

Driver’s License #/State

Check all that apply:



Relation to Head of Household

SELF

If you are separated or divorced, complete the following:

Spouse/Ex-spouse Name

Address

City

State

Zip Code

Social Security #

Birth Date

Personal Declaration

 

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OFFICIAL USE ONLY

Housing Assistant

1.

___ SSA Card on file

___ ID/Birth Certificate on file

___ Review Personal Status

___ Aged/

___ Divorce Papers

___ Divorce/Separation Certification

Family Information

2.

Last Name

First Name

MI

Soc. Sec. #

Birth Place/City, State

Birth Date

Driver’s License #/State

Check all that apply:



Relation to Head of Household

If you are separated or divorced, complete the following:

Spouse/Ex-spouse Name

Address

City

State

Zip Code

Social Security #

Birth Date

OFFICIAL USE ONLY

Housing Assistant

2.

___ SSA Card on file

___ ID/Birth Certificate on file

___ Review Personal Status

___ Aged/

___ Divorce Papers

___ Divorce/Separation Certification


3.

Last Name

First Name

MI

Soc. Sec. #

Birth Place/City, State

Birth Date

Driver’s License #/State

Check all that apply:



Relation to Head of Household

If you are separated or divorced, complete the following:

Spouse/Ex-spouse Name

Address

City

State

Zip Code

Social Security #

Birth Date

OFFICIAL USE ONLY

Housing Assistant

3.

___ SSA Card on file

___ ID/Birth Certificate on file

___ Review Personal Status

___ Aged/

___ Divorce Papers

___ Divorce/Separation Certification


4.

Last Name

First Name

MI

Soc. Sec. #

Birth Place/City, State

Birth Date

Driver’s License #/State

Check all that apply:



Relation to Head of Household

OFFICIAL USE ONLY

Housing Assistant

4.

___ SSA Card on file

___ ID/Birth Certificate on file

___ Review Personal Status

___ Aged/

___ Divorce Papers

___ Divorce/Separation Certification

Personal Declaration

 

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Family Information

If you are separated or divorced, complete the following:

Spouse/Ex-spouse Name

Address

City

State

Zip Code

Social Security #

Birth Date

 

B. Children in Household: List all children who stay with you.

1.

Last Name

First Name

MI

Soc. Sec. #

Sex

Birth Date

Birth Place, State

School Name

Address

Zip Code

Relation to Head
of Household

Mother’s Name

Soc. Sec. #

Birth Date

Address

Father’s Name

Soc. Sec. #

Birth Date

Address

B.

1.

___ SSA Card on file

___ ID/Birth Certificate on file

___ Review information on Parents

Yes     No
Applicant     ___     ___


2.

Last Name

First Name

MI

Soc. Sec. #

Sex

Birth Date

Birth Place, State

School Name

Address

Zip Code

Relation to Head
of Household

Mother’s Name

Soc. Sec. #

Birth Date

Address

Father’s Name

Soc. Sec. #

Birth Date

Address

B.

2.

___ SSA Card on file

___ ID/Birth Certificate on file

___ Review information on Parents

Yes     No
Applicant     ___     ___


3.

Last Name

First Name

MI

Soc. Sec. #

Sex

Birth Date

Birth Place, State

School Name

Address

Zip Code

Relation to Head
of Household

Mother’s Name

Soc. Sec. #

Birth Date

Address

Father’s Name

Soc. Sec. #

Birth Date

Address

B.

3.

___ SSA Card on file

___ ID/Birth Certificate on file

___ Review information on Parents

Yes     No
Applicant     ___     ___

Personal Declaration

 

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Family Information

4.

Last Name

First Name

MI

Soc. Sec. #

Sex

Birth Date

Birth Place, State

School Name

Address

Zip Code

Relation to Head
of Household

Mother’s Name

Soc. Sec. #

Birth Date

Address

Father’s Name

Soc. Sec. #

Birth Date

Address

B.

4.

___ SSA Card on file

___ ID/Birth Certificate on file

___ Review information on Parents

Yes     No
Applicant     ___     ___


5.

Last Name

First Name

MI

Soc. Sec. #

Sex

Birth Date

Birth Place, State

School Name

Address

Zip Code

Relation to Head
of Household

Mother’s Name

Soc. Sec. #

Birth Date

Address

Father’s Name

Soc. Sec. #

Birth Date

Address

B.

5.

___ SSA Card on file

___ ID/Birth Certificate on file

___ Review information on Parents

Yes     No
Applicant     ___     ___


C. FOSTER CHILDREN:
Is anyone living in your home a foster child?
If yes, list complete name for each foster child:

 

C.

___ Documentation of Foster care status for each child.

___ Foster Care License

Yes     No
Applicant     ___     ___

 

D. LIST ALL FULL-TIME STUDENTS 18 YEARS OR OLDER:
Student’s Name Name and Address of School
Student’s Name Name and Address of School
Student’s Name Name and Address of School

D.

Yes     No
Student Aid     ___     ___

Yes     No
Student Aid     ___     ___

Yes     No
Student Aid     ___     ___

Personal Declaration

 

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Family Employment
E. WORKING:Is anyone working or expecting to work in the next 6 months?
If yes, complete the portion below. (If self-employed, please provide a ledger of income and expenses.)
1.

Name

Occupation

Gross Wage / month

Employer's Name

Address

City, State, Zip Code, Phone

Do you ever receive any of the following?
Overtime: Tips:
Bonus: Commission:

E.

1.

___ Pay stubs on file

___ Employer's report on file

___ W2/1099

Earnings Exempt:

___ Yes ____ No


2.

Name

Occupation

Gross Wage / month

Employer's Name

Address

City, State, Zip Code, Phone

Do you ever receive any of the following?
Overtime: Tips:
Bonus: Commission:

E.

2.

___ Pay stubs on file

___ Employer's report on file

___ W2/1099

Earnings Exempt:

___ Yes ____ No


3.

Name

Occupation

Gross Wage / month

Employer's Name

Address

City, State, Zip Code, Phone

Do you ever receive any of the following?
Overtime: Tips:
Bonus: Commission:

E.

3.

___ Pay stubs on file

___ Employer's report on file

___ W2/1099

Earnings Exempt:

___ Yes ____ No


4.

Name

Occupation

Gross Wage / month

Employer's Name

Address

City, State, Zip Code, Phone

Do you ever receive any of the following?
Overtime: Tips:
Bonus: Commission:

E.

4.

___ Pay stubs on file

___ Employer's report on file

___ W2/1099

Earnings Exempt:

___ Yes ____ No

Personal Declaration

 

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Income & Expenses
F. INCOME:Does anyone, including children, receive or expect to receive money from any source listed below?
Check “Yes” or “No” for each item. If yes, list who and amount received monthly
Item Yes/No Who Monthly Amount

• Training
• Work Study
• Educational Loans
• TANF
• General Relief
• Unemployment Benefits
• State Disability
• Workers Compensations
• Child Support
• Spousal Support
• Social Security
• SSI
• Pension/Retirement
• Veteran’s Benefit
• Military Allotment
• Railroad Retirement
• Interest/Asset
• Income from Rental Prop
• Second Job
• Other; Explain:

OFFICIAL USE ONLY

F.

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______


TANF or GR

Worker Name

Number

DSS Office Address

City, State, Zip

Phone

TANF or GR

Worker Name

Number

DSS Office Address

City, State, Zip

Phone

Bring your most recent proof of income and your last Federal Income Tax Return to your office appointment (examples: letter from employer, check stubs, welfare or social security award letters, bank statements, 1099 forms, etc.).


G. Do you employ the services of a Care Provider for a child 12 years or under or for a person?

If yes, complete the following:

Amount Paid

1) Care Provider Name

(check one)

Care Provider Address

Care Provider Phone

Amount Paid

2) Care Provider Name

(check one)

Care Provider Address

Care Provider Phone

OFFICIAL USE ONLY

G.

____ Third Party Verifications who pays childcare expense?

Personal Declaration

 

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Income & Expenses

H. Does anyone receive contributions, gifts or loans from any source?

If yes, complete the following:

Item Received

Value of Item

Who Gives the Item


I. Does anyone own or is anyone buying real estate, such as land and/or buildings, mobile homes, etc. anywhere?

If yes, complete the following:

Type

Address

Estimated Value


J. Does anyone, including children, have any of the following resources? Check Yes or No For each item.
If yes, list who and amount.

Item Yes/No Who Amount

• Cash
• Checking Account(s)
   How many Checking
   Accounts do you have:
• Savings Account(s)
   How many Savings
   Accounts do you have:
• Life Insurance Policy
• Trust Funds
• Stocks or Bonds
• Certificates of Deposit or
   Money Market Account
• Notes, Mortgages, or Deeds
• Retirement Accounts
• Deferred Compensation
• Safe Deposit Box
• Real Estate
• Other; Explain:

If yes to any items above, complete the following:

Type of Resource Current Value Name and Address of Institution Account Number

OFFICIAL USE ONLY

H.

____ Third Party Verifications



I.

____ Third Party Verifications

Market Value $___
Amount Owed $___
Income $ ________


J.

____ Third Party Verifications on file

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______


______

______

______

______

______

Personal Declaration

 

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Additional Information

K. Does anyone receive any income from any other source, including someone outside your household paying for any of your bills or giving you money?

If yes, please explain:


L. Does anyone own or have the use of any vehicle, such as car, truck, motor home, motorcycle, off-road vehicle, camper, boat, or any other type of vehicle?

If yes, complete the following:

Type License Tag # State Year Make and Model

M. Do you have a live-in aide?

If yes, complete the following:

Name

Social Security #

Do you pay for this service yourself?

If no, please explain:


N. Have you or any member of your household (listed above) ever been arrested for any drug related criminal activity?

If yes, please give dates, charges, city and state:


O. Have you or any member of your household (listed above) ever been arrested for any felonious violent criminal activity that has as one of its elements the use, attempted use, or threatened use physical force against a person or property of another?

If yes, please give dates, charges, and city and state:


P. Have you or any other adult member ever used any name(s)/social security number(s) other than the one you have listed?


Q. Have you or any other adult household member sold any business or asset in the last 2 years for less than full its full value?

If yes, explain:


R. Have you or any other household member lived in any rental-assisted housing?

If yes, give the details:


S. Have you ever committed any fraud in any housing assistance program or been requested to repay money for knowingly misrepresenting information for such housing programs?

If yes, explain:


T. Are there any children 7 years and under who have an elevated blood level of lead?

Personal Declaration

 

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OFFICIAL USE ONLY

K.

____

____

____



L.

____

____

____



M.

____ Physician’s Evaluation 24 hour care

____ IHSS Evaluation 24 hour care

____ Live-in Aide Certification


N.

____


O.

____


P.

____


Q.

____ Third Party Verifications of Property Value

____ Verification that Asset is no longer owned by household member

____ Disposition of proceeds

R.

___ Review for Outstanding Collections

S.

___ Review eligibility status. (Is account balance zero or up to date?)

Federal Privacy Act

U.MEDICAL EXPENSES – ELDERLY OR FAMILIES ONLY

If the head of household or the spouse of the head of household is: a) 62 years of age or older; b) ; or c) ; AND if any household member pays for medications, medical/dental treatments, medical insurance, or prescribed appliances which are not reimbursed, bring in verification of monthly/yearly costs. You may bring receipts for medicine or a statement from your pharmacist itemizing the medications and cost. Be sure to bring your medicare and insurance statements with you.

Name of Pharmacy

Address

City, State, Zip

HEAD OF HOUSEHOLD ONLY, please complete: (Enter code which best describes your race.)

Race ( )

 

Ethnicity ( )

1

- White

3 – American Indian

1

– Hispanic

 

 

Native American

 

 

2

– Black or

4 – Asian/Pacific Islander

2

– Non Hispanic

 

African American

 

 

 

 

 

 

 

 

FEDERAL PRIVACY ACT NOTICE

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.

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.

You must provide all the information requested by the public housing agency, including all social security numbers you, and all other household members age six (6) years and older, have and use. Giving the social security numbers of all household members 6 years of age 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; the U.S. Housing ACT of 1937 (42 U.S.C., 1437 et seq.), Title VI 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.

Personal Declaration

 

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Do Not Sign

APPLICANT/TENANT CERTIFICATION & NOTICE

I/We certify that the information* given to the Public Housing Authority on household composition, income, net family assets and allowances and deductions is accurate and complete to the best of my/our knowledge and belief. I/We understand that false statements or information are punishable under Federal law. I/We also understand that false statements or information are grounds for termination of housing assistance and termination of tenancy.

*After verification by this PHA, the information will be submitted to HUD on Form HUD-50058 (Tenant Data Summary, a computer-generated facsimile of the form or on magnetic tape. See the Federal Privacy Act Notice for more information about its use.)

WARNING! TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRADULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES.

I do hereby swear and attest that all the information above about me and my household is true and correct. I also understand that all changes in household members or income must be reported to the Public Housing Authority IN WRITING immediately.

I declare under penalty of perjury under the laws of the United States of America and the State of South Carolina that the information contained in this statement of facts is true, correct, and complete.

WAIT! THIS FORM IS TO BE SIGNED AT YOUR APPOINTMENT. ALL ADULT MEMBERS MUST SIGN THIS FORM IN FRONT OF A HOUSING COMMISISON STAFF MEMBER.

_________________________________________________

____________________________________________________

Signature of Head of Household

Date

Signature of Head of Household

Date

_________________________________________________

____________________________________________________

Signature of Other Adult

Date

Signature of Other Adult

Date

PHA OFFICIAL’S CERTIFICATION AND NOTICE FOR TENANT’S FILE

I certify that:

1.The information given to the Public Housing Authority by the household of _______________________________ on household composition, income, net family assets, and allowances and deductions has been verified as required by Federal law;

2.The family was eligible at admission; and

3.The family has certified that it has given our agency accurate and complete information.

________________________________________________________________________________________________

PHA Official or Representative Date

FILE NAME _______________________________________ SOCIAL SECURITY NO. __________________________

Personal Declaration

 

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Residential History

TENANCY HISTORY/INFORMATION SHEET


NAME

HOME TELEPHONE

 

(Check One)

1. Are you visually impaired? (optional)

2. Are you hearing impaired? (optional)

3. Does anyone in your family need a
wheelchair? (optional)

4. Can you live in an upstairs apartment?

5. Will you have any pets?

6. Has anyone on this application ever been arrested
or detained by the police for a crime (other than traffic
violations)?

If yes, who?

Describe criminal activity (conviction/pending):

Action taken/judgment:

7. Has anyone on this application ever been evicted from a
rental unit within the last five (5) years?

If yes, give date, address and reason why:

Below please list your residence history for the past five (5) years. Use additional paper, if necessary.

1. PRESENT ADDRESS:

 

STREET

CITY/STATE

ZIP CODE

FROM: TO:

NAME OF OWNER/MANAGEMENT COMPANY

ADDRESS

CITY/STATE

ZIP CODE

REASON FOR LEAVING:


2. PREVIOUS ADDRESS:

 

STREET

CITY/STATE

ZIP CODE

FROM: TO:

NAME OF OWNER/MANAGEMENT COMPANY

ADDRESS

CITY/STATE

ZIP CODE

REASON FOR LEAVING:

Personal Declaration

 

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Residential History
3. PREVIOUS ADDRESS:

 

STREET

CITY/STATE

ZIP CODE

FROM: TO:

NAME OF OWNER/MANAGEMENT COMPANY

ADDRESS

CITY/STATE

ZIP CODE

REASON FOR LEAVING:


4. PREVIOUS ADDRESS:

 

STREET

CITY/STATE

ZIP CODE

FROM: TO:

NAME OF OWNER/MANAGEMENT COMPANY

ADDRESS

CITY/STATE

ZIP CODE

REASON FOR LEAVING:


5. PREVIOUS ADDRESS:

 

STREET

CITY/STATE

ZIP CODE

FROM: TO:

NAME OF OWNER/MANAGEMENT COMPANY

ADDRESS

CITY/STATE

ZIP CODE

REASON FOR LEAVING:


6. PREVIOUS ADDRESS:

 

STREET

CITY/STATE

ZIP CODE

FROM: TO:

NAME OF OWNER/MANAGEMENT COMPANY

ADDRESS

CITY/STATE

ZIP CODE

REASON FOR LEAVING:


7. PREVIOUS ADDRESS:

 

STREET

CITY/STATE

ZIP CODE

FROM: TO:

NAME OF OWNER/MANAGEMENT COMPANY

ADDRESS

CITY/STATE

ZIP CODE

REASON FOR LEAVING:

Personal Declaration

 

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Financial Obligations

FINANCIAL OBLIGATIONS IF APPLICABLE (I.E., CAR PAYMENTS, LOANS, ETC.):

 

PAYMENTS TO:

AMOUNT PER MONTH:

 

PAYMENTS TO:

AMOUNT PER MONTH:

1.

$

 

4.

$

2.

$

 

5.

$

3.

$

 

6.

$

WARNING! TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDLENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES.

I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCIRATE. I HEREBY AUTHORIZE THE PUBLIC HOUSING AUTHORITY TO VERIFY ANY INFORMATION REGARDING RENTAL HISTORY OR CRIMINAL ACTIVITY, INCLUDING OBTAINING A CONSUMER OR INVESTIGATIVE CREDIT REPORT.

I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES OF AMERICA AND THE STATE OF SOUTH CAROLINA THAT THE INFORMAITON CONTAINED IN THIS STATEMENT OF FACTS IS TRUE, CORRECT, AND COMPLETE

_________________________________________________________

________________________________

SIGNATURE

DATE

_________________________________________________________

________________________________

SIGNATURE

DATE

_________________________________________________________

________________________________

SIGNATURE

DATE

Personal Declaration

 

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