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