DOCUMENTS REQUIRED FOR YOUR RECERTIFICATION PACKET

Transcription

1 1A Lwndes Avenue Huntingtn Statin, N.Y (631) Fax (631) DOCUMENTS REQUIRED FOR YOUR RECERTIFICATION PACKET If any member f yur husehld receives any f the fllwing types f incme listed belw, please prvide the fllwing: Mailing name, address and telephne number f the surce f incme and dcumentatin abut current amunts received. (Fr example, Award Letters, cpies f paystubs). I. INFORMATION ABOUT YOUR HOUSEHOLD INCOME AND ASSETS: A) EMPLOYMENT INCOME FOR EVERY MEMBER OF YOUR HOUSEHOLD THAT IS WORKING, PLEASE PROVIDE THE FOLLOWING: 1. Paystubs Current & cnsecutive (Fur if paid weekly r tw if paid bi-weekly/semi-mnthly). 2. Latest W-2 Frms 3. Cpy f yur mst recent Tax Return 4. Other types f expected incme such as tips, vertime, cmmissins, prfit sharing prgrams, etc. B) BENEFIT & SUPPORT INCOME: PROOF MUST BE CURRENT 1. Unemplyment Benefits WEEKLY PRINTOUT 2. CURRENT Scial Security Award Letter NO MORE THAN 30 DAYS 3. Supplemental Scial Security Award Letter NO MORE THAN 30 DAYS 4. Child Supprt - WEEKLY OR MONTHLY PRINTOUT 5. Public Assistance and/r Fd Stamps CURRENT BUDGET PRINTOUT 6. Pensin, Annuities, Disability Incme, Wrkmen s Cmpensatin, Alimny, etc. 7. Regular Supprt frm family members and/r friends. C) BANK STATEMENTS Three cnsecutive bank statements fr all accunts fr all family members ver 18 (i.e., Checking, savings, CDs, etc.) D) STOCKS/BONDS Current statement indicating VALUE f stck, and dividend amunt. E) LIFE INSURANCE Cash surrender value nly (please attach table f cash value). (CONTINUED ON NEXT PAGE).

2 II. III. FULL TIME COLLEGE STUDENT STATUS Please prvide a LETTER frm the schl s REGISTRAR OFFICE indicating current F/T student status (DO NOT prvide an acceptance letter, bill r schedule). MEDICAL EXPENSES If yu r yur spuse are 62 years f age; r disabled; r handicapped and yu have medical expenses that exceed yur insurance cverage, please prvide dcumentatin that the medical bills have been paid including the actual bill and cpies f cancelled checks, receipts, etc. If yu have utstanding medical bills and yu have entered int repayment agreement with yur dctr r hspital, please prvide the name and address f the dctr r hspital in rder that we can verify a repayment agreement and send a cpy f the agreement with prf f payment each mnth (i.e. canceled checks). Nte: Medical expenses nly apply if head f husehld r spuse is 62 years f age r lder r disabled r handicapped. Dcumentatin f medical must be prvided. Examples f medical expenses are: -Medical cverage (If yu receive Medicare, prvide previus years).

3 TOWN OF HUNTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE HUNTINGTON STATION, NY FAX Dear Tenant: IN ACCORDANCE WITH FEDERAL LAW, THIS OFFICE MAY TERMINATE RENTAL ASSISTANCE TO TENANT/FAMILY FOR THE FOLLOWING REASONS: IF THE FAMILIY VIOLATES ANY FAMILY OBLIGATIONS UNDER THE PROGRAM. IF THE FMAILY FAILS TO NOTIFY SECTION 8 IN WRITING OF ALL INCOME AND FAMILY COMPOSITION CHANGES IMMEDIATELY. IF ANY MEMBER OF THE FAMILY HAS BEEN EVICTED FROM PUBLIC HOUSING. IF A HOUSING AUTHORITY HAS EVER TERMINATED ASSISTANCE UNDER THE HOUSING CHOICE VOUCHER PROGRAM FOR ANY MEMBER OF THE FAMILY. IF ANY MEMBER OF THE FAMILY COMMITS DRUG-RELATED CRIMINAL ACTIVITY, OR VIOLENT CRIMINAL ACTIVITY. IF ANY MEMBER OF THE FAMILY COMMITS FRAUD, BRIBERY OR ANY OTHER CORRUPT OF CRIMINAL ACT IN CONNECTION WITH FEDERAL HOUSING PROGRAM. IF ANY FAMILY CURRENTLY OWES RENT OR OTHER AMOUNTS TO HUNTINGTON HOUSING AUTHORITY OR TO ANOTHER HOUSING AUTHORITY IN CONNECTION WITH THE SECTION 8 OR PUBLIC HOUSING AUTHORITY UNDER THE UNITED STATES HOUSING ACT OF IF THE FAMILY HAS NOT REIMBURSED ANY HOUSING AUTHORITY FOR AMOUNTS PAID TO AN OWNER UNDER A HAP CONTRACT FOR RENT, DAMAGES TO THE UNIT, OR OTHER AMOUNTS OWED BY THE FAMILY UNDER THE LEASE. IF THE FAMILY BREACHES AN AGREEMENT WITH HHA TO PAY AMOUNTS OWED TO HHA OR AMOUNTS PAID TO AN OWNER BY HHA (HHA AT ITS DISCRETION MAY OFFER A FAMILY THE OPPORTUNITY TO ENTER AN AGREEMENT TO PAY AMOUNTS OWED TO HHA OR AMOUNTS PAID TO AN OWNER BY HHA.) HHA MAY PRESCRIBE THE TERMS OF THE AGREEMENT. IF THE FAMILY HAS ENGAGED IN THREATENING, ABUSIVE, OR VIOLENT BEHAVIOR TOWARDS THE HHA PERSONNEL. IF YOUR ASSISTANCE IS TERMINATED FOR ONE OF THE ABOVE REASONS, BOTH YOU AND THE OWNER WILL BE PROVIDED WITH A 30 DAY WRITTEN NOTICE OF TERMINATION WHICH STATES: THE REASONS FOR THE TERMINATION. THE EFFECTIVE DATE OF THE TERMINATION. THE FAMILY S RIGHT TO REQUEST AN INFORMAL HEARING. ANYONE 18 OR OLDER MUST SIGN BELOW. I HAVE READ THE ABOVE AND UNDERSTAND WHAT I HAVE READ. HEAD OF HOUSEHOLD DATE SPOUSE/CO-HEAD DATE OTHER ADULT DATE OTHER ADULT DATE

4 TOWN OF HUNTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE HUNTINGTON STATION, NY FAX PERSONAL DECLARATION THIS FORM MUST BE COMPLETED IN INK IN YOUR OWN HANDWRITING. YOU MUST USE THE CORRECT NAME FOR EACH MEMBER OF YOUR HOUSEHOLD. ALL ADULT MEMBERS OF THE HOUSEHOLD MUST SIGN BELOW CERTIFYING THE INFORMATION PERTAINING TO THEM. PLEASE PRINT CLEARLY. I. HOUSEHOLD COMPOSITION: LIST ALL PERSONS WHO ARE LIVING IN YOUR HOME, LISTING THE HEAD OF HOUSEHOLD FIRST. 1. ADULTS (LEGAL NAME) DATE OF BIRTH RELATIONSHIP TO HOH SOCIAL SECURITY # INDICATE: (M) MARRIED (S) SEPARATED (D) DIVORCED HOUSEHOLD MEMBER IN COLLEGE? YES/NO CHILDREN (NAME AS IT APPEARS ON SS CARD) 1. DATE OF BIRTH RELATIONSHIP TO HOH SCHOOL NAME ABSENT PARENT S NAME ABSENT PARENT S ADDRESS PRESENT ADDRESS EMERGENCY CONTACT NAME NAME STREET ADDRESS STREET ADDRESS CITY, STATE, ZIP CITY, STATE, ZIP PHONE # PHONE #

5 II. TOTAL HOUSEHOLD INCOME: LIST ALL MONEY EARNED OR RECEIVED BY EVERYONE LIVING IN YOUR HOUSEHOLD THAT INCLUDES MONEY FROM WAGES, SELF-EMPLOYMENT, CHILD SUPPORT, CONTRIBUTIONS, SOCIAL SECURITY, DISABILITY PAYMENT, WORKERS COMPENSATION, RETIREMENT BENEFITS, TANF, VETERAN S BENEFITS, RENTAL PROPERTY INCOME, STOCK DIVIDENDS FROM BANK ACCOUNTS, ALIMONY AND ALL OTHER SOURCES. LIST AMOUNTS RECEIVED BELOW: 1. HOUSEHOLD MEMBER EMPLOYER TOTAL WEEKLY WAGES TANF BENEFITS CHILD SUPPORT MONTHLY SOCIAL SECURITY BENEFITS UNEMPLOYMENT BENEFITS ALL OTHER INCOME III. ASSETS: IF YES TO ANY, LIST BELOW. 1. DO YOU OR ANY HOUSEHOLD MEMBERS OWN OR HAVE AN INTEREST IN ANY REAL ESTATE, HOMES AND/OR MOBILE HOME? YES/ NO 2. HAVE YOU SOLD ANY REAL ESTATE IN THE LAST TWO YEARS? YES/NO 3. DO YOU OWN ANY SAVINGS ACCOUNT? YES/ NO IF YES, LIST BANK ACCOUNT NUMBERS AND AMOUNTS. 3. DO YOU OWN A CAR? YES /NO MODEL/YEAR LICENSE PLATE # 4. DOES ANYONE OUTSIDE OF YOUR HOUSEHOLD PAY FOR ANY OF YOUR BILLS OR GIVE YOU MONEY? YES/NO IF YES, EXPLAIN: 5. HAVE YOU OR ANY OTHER ADULT MEMBERS EVER USED ANY NAME(S) OR SOCIAL SECURITY NUMBER(S) OTHER THAN THE ONE YOU ARE CURRENTLY USING? YES/NO IF YES, EXPLAIN: 6. HAVE YOU OR ANY OTHER MEMBERS LIVED IN ANY ASSISTED HOUSING? YES/NO IF YES, EXPLAIN: 7. HAVE YOU OR ANYONE IN YOUR HOUSEHOLD EVER BEEN ARRESTED, CHARGED, AND/OR CONVICTED OF ANY CRIME OTHER THAN A TRAFFIC VIOLATION? YES/NO IF YES, LIST WHERE AND WHEN: 8. HAVE YOU EVER COMMITTED ANY FRAUD IN A FEDERALLY ASSISTED HOUSING PROGRAM OR BEEN REQUESTED TO REPAY MONEY FOR KNOWINGLY MISREPRESENTING INFORMATION FOR SUCH HOUSING PROGRAMS? YES/NO IF YES, EXPLAIN: I DO HEREBY SWEAR AND ATTEST THAT ALL OF THE INFORMATION ABOVE ABOUT IS TRUE AND CORRECT. I ALSO UNDERSTAND THAT ALL CHANGES IN THE INCOME OF ANY MEMBER OF THE HOUSEHOLD AS WELL AS ANY CHANGES IN THE HOUSEHOLD MEMBERS MUST BE REPORTED TO THE HUNTINGTON HOUSING AUTHORITY IN WRITING IMMEDIATELY. SIGNATURE OF HEAD OF HOUSEHOLD DATE SIGNATURE OF CO-HEAD OF HOUSEHOLD DATE SIGNATURE OF OTHER ADULT DATE SIGNATURE OF OTHER ADULT DATE 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 FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES.

6 Authrizatin fr the Release f Infrmatin/ Privacy Act Ntice (Crss ut space if nne) U.S. Department f Husing and Urban Develpment (Crss ut space if nne) Authrity: Sectin 904 f the Stewart B. McKinney Hmeless Assistance Amendments Act f 1988, as amended by Sectin 903 f the Husing and Cmmunity Develpment Act f 1992 and Sectin 3003 f the Omnibus Budget Recnciliatin Act f This law is fund at 42 U.S.C This law requires that yu sign a cnsent frm authrizing: (1) HUD and the Husing Agency/Authrity (HA) t request verificatin f salary and wages frm current r previus emplyers; (2) HUD and the HA t request wage and unemplyment cmpensatin claim infrmatin frm the state agency respnsible fr keeping that infrmatin; (3) HUD t request certain tax return infrmatin frm the U.S. Scial Security Administratin and the U.S. Internal Revenue Service. The law als requires independent verificatin f incme infrmatin. Therefre, HUD r the HA may request infrmatin frm financial institutins t verify yur eligibility and level f benefits. Purpse: In signing this cnsent frm, yu are authrizing HUD and the abve-named HA t request incme infrmatin frm the surces listed n the frm. HUD and the HA need this infrmatin t verify yur husehld s incme, in rder t ensure that yu are eligible fr assisted husing benefits and that these benefits are set at the crrect level. HUD and the HA may participate in cmputer matching prgrams with these surces in rder t verify yur eligibility and level f benefits. Uses f Infrmatin t be Obtained: HUD is required t prtect the incme infrmatin it btains in accrdance with the Privacy Act f 1974, 5 U.S.C. 552a. HUD may disclse infrmatin (ther than tax return infrmatin) fr certain rutine uses, such as t ther gvernment agencies fr law enfrcement purpses, t Federal agencies fr emplyment suitability purpses and t HAs fr the purpse f determining husing assistance. The HA is als required t prtect the incme infrmatin it btains in accrdance with any applicable State privacy law. HUD and HA emplyees may be subject t penalties fr unauthrized disclsures r imprper uses f the incme infrmatin that is btained based n the cnsent frm. Private wners may nt request r receive infrmatin authrized by this frm. Wh Must Sign the Cnsent Frm: Each member f yur husehld wh is 18 years f age r lder must sign the cnsent frm. Additinal signatures must be btained frm new adult members jining the husehld r whenever members f the husehld becme 18 years f age. Persns wh apply fr r receive assistance under the fllwing prgrams are required t sign this cnsent frm: PHA-wned rental public husing Turnkey III Hmewnership Opprtunities Mutual Help Hmewnership Opprtunity Sectin 23 and 19(c) leased husing Sectin 23 Husing Assistance Payments HA-wned rental Indian husing Sectin 8 Rental Certificate Sectin 8 Rental Vucher Sectin 8 Mderate Rehabilitatin Failure t Sign Cnsent Frm: Yur failure t sign the cnsent frm may result in the denial f eligibility r terminatin f assisted husing benefits, r bth. Denial f eligibility r terminatin f benefits is subject t the HA s grievance prcedures and Sectin 8 infrmal hearing prcedures. Surces f Infrmatin T Be Obtained State Wage Infrmatin Cllectin Agencies. (This cnsent is limited t wages and unemplyment cmpensatin I have received during perid(s) within the last 5 years when I have received assisted husing benefits.) U.S. Scial Security Administratin (HUD nly) (This cnsent is limited t the wage and self emplyment infrmatin and payments f retirement incme as referenced at Sectin 6103(l)(7)(A) f the Internal Revenue Cde.) U.S. Internal Revenue Service (HUD nly) (This cnsent is limited t unearned incme [i.e., interest and dividends].) Infrmatin may als be btained directly frm: (a) current and frmer emplyers cncerning salary and wages and (b) financial institutins cncerning unearned incme (i.e., interest and dividends). I understand that incme infrmatin btained frm these surces will be used t verify infrmatin that I prvide in determining eligibility fr assisted husing prgrams and the level f benefits. Therefre, this cnsent frm nly authrizes release directly frm emplyers and financial institutins f infrmatin regarding any perid(s) within the last 5 years when I have received assisted husing benefits. HUD-9886

7 Cnsent: I cnsent t allw HUD r the HA t request and btain incme infrmatin frm the surces listed n this frm fr the purpse f verifying my eligibility and level f benefits under HUD s assisted husing prgrams. I understand that HAs that receive incme infrmatin under this cnsent frm cannt use it t deny, reduce r terminate assistance withut first independently verifying what the amunt was, whether I actually had access t the funds and when the funds were received. In additin, I must be given an pprtunity t cntest thse determinatins. This cnsent frm expires 15 mnths after signed. Privacy Act Ntice. Authrity: The Department f Husing and Urban Develpment (HUD) is authrized t cllect this infrmatin by the U.S. Husing Act f 1937 (42 U.S.C et. seq.), Title VI f the Civil Rights Act f 1964 (42 U.S.C. 2000d), and by the Fair Husing Act (42 U.S.C ). The Husing and Cmmunity Develpment Act f 1987 (42 U.S.C. 3543) requires applicants and participants t submit the Scial Security Number f each husehld member wh is six years ld r lder. Purpse: Yur incme and ther infrmatin are being cllected by HUD t determine yur eligibility, the apprpriate bedrm size, and the amunt yur family will pay tward rent and utilities. Other Uses: HUD uses yur family incme and ther infrmatin t assist in managing and mnitring HUD-assisted husing prgrams, t prtect the Gvernment s financial interest, and t verify the accuracy f the infrmatin yu prvide. This infrmatin may be released t apprpriate Federal, State, and lcal agencies, when relevant, and t civil, criminal, r regulatry investigatrs and prsecutrs. Hwever, the infrmatin will nt be therwise disclsed r released utside f HUD, except as permitted r required by law. Penalty: Yu must prvide all f the infrmatin requested by the HA, including all Scial Security Numbers yu, and all ther husehld members age six years and lder, have and use. Giving the Scial Security Numbers f all husehld members six years f age and lder is mandatry, and nt prviding the Scial Security Numbers will affect yur eligibility. Failure t prvide any f the requested infrmatin may result in a delay r rejectin f yur eligibility apprval. Penalties fr Misusing this Cnsent: HUD-9886

8 TOWN OF HUNTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE HUNTINGTON STATION, NY FAX Request Date: Name: LAST FIRST MIDDLE CURRENT ADDRESS: PREVIOUS ADDRESS: SOCIAL SECURITY #: DATE OF BIRTH: EMPLOYER: I HEREBY AUTHORIZE HUNTINGTON HOUSING AUTHORITY TO OBTAIN INFORMATION IT DEEMS DESIRABLE IN THE PROCESSING OF MY APPLICATION, INCLUDING CREDIT REPORT, CIVIL OR CRIMINAL ACTION, RENTAL HISTORY OF EMPLOYMENT/SALARY DETAIL, AND ANY OTHER RELEVANT INFORMATION; AND RELEASE HUNTINGTON HOUSING AUTHORITY ITS EMPLOYEES AND AGENT FROM ALL LIABILITIES AND DAMAGE, WHATEVER INCURRED IN FURNISHING OR OBTAIN SUCH INFORMATION. HEAD OF HOUSEHOLD SPOUSE/CO-HEAD OTHER ADULT OTHER ADULT DATE DATE DATE DATE

9 TOWN OF HUNTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE HUNTINGTON STATION, NY FAX Request Date: Name: LAST FIRST MIDDLE CURRENT ADDRESS: PREVIOUS ADDRESS: SOCIAL SECURITY #: DATE OF BIRTH: EMPLOYER: I HEREBY AUTHORIZE HUNTINGTON HOUSING AUTHORITY TO OBTAIN INFORMATION IT DEEMS DESIRABLE IN THE PROCESSING OF MY APPLICATION, INCLUDING CREDIT REPORT, CIVIL OR CRIMINAL ACTION, RENTAL HISTORY OF EMPLOYMENT/SALARY DETAIL, AND ANY OTHER RELEVANT INFORMATION; AND RELEASE HUNTINGTON HOUSING AUTHORITY ITS EMPLOYEES AND AGENT FROM ALL LIABILITIES AND DAMAGE, WHATEVER INCURRED IN FURNISHING OR OBTAIN SUCH INFORMATION. HEAD OF HOUSEHOLD SPOUSE/CO-HEAD OTHER ADULT OTHER ADULT DATE DATE DATE DATE

10 TOWN OF HUNGTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE HUNTINGTON STATION, NY PHONE FAX APPLICANT/TENANT CERTIFICATION APPLICANT(S )/TENANT(S ) STATEMENT I/WE CERTIFY THAT THE INFORMATION GIVEN TO THE TOWN OF HUNTINGTON HOUSING AUTHORITY AGENCY ON HOUSEHOLD COMPOSITION, INCOME THAT NET FAMILY ASSETS AND ALLOWANCES AND DEDUCTIONS IS ACCURATE AND COMPLETED THE BEST OF MY KNOWLEDGE AND BELIEF. I/WE UNDERSTAND THAT FALSE STATEMENTS OR INFORMATION ARE PUNISHABLE UNDER FEDERAL AND/OR STATE LAW. I/WE ALSO UNDERSTAND THAT FALSE STATEMENTS OR INFORMATION ARE GROUNDS FOR TERMINATION OF HOUSING ASSISTANCE AND TERMINATION OF TENANCY. SIGNATURE OF HEAD OF HOUSEHOLD SIGNATURE OF SPOUSE SIGNATURE OF OTHER ADULT SIGNATURE OF OTHER ADULT DATE DATE DATE DATE IF YOU BELIEVE YOU HAVE BEEN DISCRIMINATED AGAINST, YOU MAY CALL THE FAIR HOUSING AND EQUAL OPPORTUNITY NATIONAL TOLL-FREE HOTLINE AT (WITHIN THE WASHINGTON D.C.- METROPOLITAN AREA, CALL ) *AFTER VERIFICATION BY THIS HOUSING AGENCY, INFORMATION WILL BE SUBMITTED TO THE DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ON FORM HUD (TENANT DATA SUMMARY), A COMPUTER-GENERATED FACSIMILE OF THE FORM OR ON MAGNETIC TAPE. SEE THE FEDERAL, PRIVACY ACT STATEMENT FOR MORE INFORMATION ABOUT ITS USE.

11 TOWN OF HUNTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE HUNTINGTON STATION, NY PHONE FAX EMPLOYMENT VERIFICATION FORM DATE: APPLICANT/TENANT (PRINT NAME): EMPLOYER S NAME: EMPLOYER S ADDRESS: I HEREBY AUTHORIZE MY EMPLOYER TO RELEASE ALL OF MY INCOME INFORMATION TO THE TOWN OF HUNTINGTON HOUSING AUTHORITY. SOCIAL SECURITY NUMBER: SIGNATURE OF APPLICANT/TENANT: FOR EMPLOYER S USE ONLY PLEASE COMPLETE THE FOLLOWING FORM AND RETURN YOUR REPLY TO THE ADDRESS STATED ABOVE. ALL INFORMATION WILL BE IN CONFIDENCE. YOUR IMMEDIATE ATTENTION IS GREATLY APPRECIATED. -THE TOWN OF HUNTINGTON HOUSING AUTHORITY TITLE OF POSITION HELD: DATE HIRED: PRESENT STATUS: WAGES PAID (CIRCLE ONE): WEEKLY, BI-WEEKLY, SEMI-MONTHLY OR MONTHLY. HOURLY RATE: IF HOURLY, INDICATE NUMBER OF HOURS WORKED PER WEEK: GROSS RATE OF PAY: $ AMOUNT PAID GROSS YEAR TO DATE: $ AS OF: SALARIED EMPLOYEE: DOES THE EMPLOYEE RECEIVE THE FOLLOWING?: NIGHT DIFFERENTIAL PERIODS OF VACATION WITH PAY COMMISSION TIPS BONUS OVER-TIME OTHER IF YOU CHECKED ANY OF THE ABOVE, PLEASE SPECIFY:. SIGNATURE OF AUTHORIZED PERSON DATE:

12 TOWN OF HUNTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE HUNTINGTON STATION, NY PHONE FAX EMPLOYMENT VERIFICATION FORM DATE: APPLICANT/TENANT (PRINT NAME): EMPLOYER S NAME: EMPLOYER S ADDRESS: I HEREBY AUTHORIZE MY EMPLOYER TO RELEASE ALL OF MY INCOME INFORMATION TO THE TOWN OF HUNTINGTON HOUSING AUTHORITY. SOCIAL SECURITY NUMBER: SIGNATURE OF APPLICANT/TENANT: FOR EMPLOYER S USE ONLY PLEASE COMPLETE THE FOLLOWING FORM AND RETURN YOUR REPLY TO THE ADDRESS STATED ABOVE. ALL INFORMATION WILL BE IN CONFIDENCE. YOUR IMMEDIATE ATTENTION IS GREATLY APPRECIATED. -THE TOWN OF HUNTINGTON HOUSING AUTHORITY TITLE OF POSITION HELD: DATE HIRED: PRESENT STATUS: WAGES PAID (CIRCLE ONE): WEEKLY, BI-WEEKLY, SEMI-MONTHLY OR MONTHLY. HOURLY RATE: IF HOURLY, INDICATE NUMBER OF HOURS WORKED PER WEEK: GROSS RATE OF PAY: $ AMOUNT PAID GROSS YEAR TO DATE: $ AS OF: SALARIED EMPLOYEE: DOES THE EMPLOYEE RECEIVE THE FOLLOWING?: NIGHT DIFFERENTIAL PERIODS OF VACATION WITH PAY COMMISSION TIPS BONUS OVER-TIME OTHER IF YOU CHECKED ANY OF THE ABOVE, PLEASE SPECIFY:. SIGNATURE OF AUTHORIZED PERSON DATE:

13 TOWN OF HUNGTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE HUNTINGTON STATION, NY FAX STATEMENT OF SELF EMPLOYMENT EARNINGS NAME: DATE: ADDRESS:_ SOCIAL SECURITY NUMBER: I AM SELF EMPLOYED AS A AND I ESTIMATE THAT MY GROSS INCOME FOR THE NEXT 12 MONTHS WILL BE $. I CERTIFY THAT THE ABOVE IS TRUE AND CORRECT AND I UNDERSTAND THAT ACCORDING TO FEDERAL LAW IT IS A CRIMINAL OFFENSE TO MAKE ANY FALSE STATEMENTS TO THE INTERNAL REVENUE SERVICE REGARDING MATTERS WITHIN THEIR JURISDICTION. SIGNATURE: DATE: STATE OF: COUNTY OF: SIGNED, THIS DAY OF 20 IN THE PRESENCE OF (NOTARY S SIGNATURE)

14 TOWN OF HUNTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE HUNTINGTON STATION, NY PHONE FAX TO BE COMPLETED BY AN ADULT (18 OR OLDER) WHO CURRENTLY HAS NO INCOME HEAD OF HOUSEHOLD: DATE: HOUSEHOLD NAME: 1. I HEREBY CERTIFY THAT I DO NOT INDIVIDUALLY RECEIVE INCOME FROM ANY OF THE FOLLOWING SOURCES: WAGES FROM EMPLOYMENT (INCLUDING COMMISSIONS, TIPS, BONUSES, FEES, ETC.) INCOME FROM OPERATION OF A BUSINESS RENTAL INCOME FROM REAL OR PERSONAL PROPERTY INTEREST OR DIVIDENDS FROM ASSETS SOCIAL SECURITY PAYMENTS, ANNUITIES, INSURANCE POLICIES, RETIREMENT FUNDS, DEATH BENEFITS UNEMPLOYMENT OR DISABILITY PAYMENTS PUBLIC ASSISTANCE PAYMENTS PERIODIC ALLOWANCES SUCH AS ALIMONY, CHILD SUPPORT, OR GIFTS RECEIVED FROM PERSONS NOT LIVING IN MY HOUSEHOLD SALES FROM SELF-EMPLOYMENT RESOURCES (AVON, MARY KAY, ETC.) ANY OTHER SOURCES NOT NAMED ABOVE 2. I CURRENTLY HAVE NO INCOME OF ANY KIND AND THERE IS NO IMMINENT CHANGE EXPECTED IN MY FINANCIAL STATUS OR EMPLOYMENT STATUS DURING THE NEXT 12 MONTHS. 3. I WILL BE USING THE FOLLOWING SOURCES OF FUNDS TO PAY FOR RENT AND OTHER NECESSITIES: UNDER PENALTY OF PERJURY, I CERTIFY THAT THE INFORMATION PRESENTED IN THIS CERTIFICATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. THE UNDERSIGNED FURTHER UNDERSTANDS THAT PROVIDING FALSE REPRESENTATIONS HEREIN CONSTITUTES AN ACT OF FRAUD. FALSE, MISLEADING OR INCOMPLETE INFORMATION MAY RESULT IN THE TERMINATION OF A LEASE AGREEMENT. 4. NAME OF APPLICANT: DATE: 5. SIGNATURE OF APPLICANT: 6. SIGNATURE OF NOTARY: 7. STATE COMMISSIONS ISSUED: 8. COMMISSION EXPIRATION DATE:

15 TOWN OF HUNTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE HUNTINGTON STATION, NY PHONE FAX TO BE COMPLETED BY AN ADULT (18 OR OLDER) WHO CURRENTLY HAS NO INCOME HEAD OF HOUSEHOLD: DATE: HOUSEHOLD NAME: 1. I HEREBY CERTIFY THAT I DO NOT INDIVIDUALLY RECEIVE INCOME FROM ANY OF THE FOLLOWING SOURCES: WAGES FROM EMPLOYMENT (INCLUDING COMMISSIONS, TIPS, BONUSES, FEES, ETC.) INCOME FROM OPERATION OF A BUSINESS RENTAL INCOME FROM REAL OR PERSONAL PROPERTY INTEREST OR DIVIDENDS FROM ASSETS SOCIAL SECURITY PAYMENTS, ANNUITIES, INSURANCE POLICIES, RETIREMENT FUNDS, DEATH BENEFITS UNEMPLOYMENT OR DISABILITY PAYMENTS PUBLIC ASSISTANCE PAYMENTS PERIODIC ALLOWANCES SUCH AS ALIMONY, CHILD SUPPORT, OR GIFTS RECEIVED FROM PERSONS NOT LIVING IN MY HOUSEHOLD SALES FROM SELF-EMPLOYMENT RESOURCES (AVON, MARY KAY, ETC.) ANY OTHER SOURCES NOT NAMED ABOVE 2. I CURRENTLY HAVE NO INCOME OF ANY KIND AND THERE IS NO IMMINENT CHANGE EXPECTED IN MY FINANCIAL STATUS OR EMPLOYMENT STATUS DURING THE NEXT 12 MONTHS. 3. I WILL BE USING THE FOLLOWING SOURCES OF FUNDS TO PAY FOR RENT AND OTHER NECESSITIES: UNDER PENALTY OF PERJURY, I CERTIFY THAT THE INFORMATION PRESENTED IN THIS CERTIFICATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. THE UNDERSIGNED FURTHER UNDERSTANDS THAT PROVIDING FALSE REPRESENTATIONS HEREIN CONSTITUTES AN ACT OF FRAUD. FALSE, MISLEADING OR INCOMPLETE INFORMATION MAY RESULT IN THE TERMINATION OF A LEASE AGREEMENT. 4. NAME OF APPLICANT: DATE: 5. SIGNATURE OF APPLICANT: 6. SIGNATURE OF NOTARY: 7. STATE COMMISSIONS ISSUED: 8. COMMISSION EXPIRATION DATE:

16 TOWN OF HUNTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE HUNTINGTON STATION, NY PHONE FAX PUBLIC ASSISTANCE INCOME VERIFICATION HEAD OF HOUSEHOLD DATE: SOCIAL SECURITY #: PA CASE#: FS CASE#: ALL HOUSEHOLD MEMBERS ON CASE: NAME: SSN: NAME: SSN: NAME: SSN: NAME: SSN: NAME: SSN: NAME: SSN: CURRENT ADDRESS: THE ABOVE NAMED HEAD OF HOUSEHOLD HAS APPLIED FOR, OR IS ALREADY PARTICIPATING IN THE FOLLOWING HOUSING PROGRAM. ( )PUBLIC HOUSING ( )HOUSING CHOICE VOUCHER PLEASE PROVIDE THIS AGENCY WITH A COPY OF THE CURRENT BUDGET FOR THIS HOUSEHOLD AND FOR ANY OTHER HOUSEHOLD MEMBER AT THIS ADDRESS. SIGNATURE OF APPLICANT/TENANT HOUSING AGENCY REPRESENTATIVE/PHONE # DATE

17 TOWN OF HUNGTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE HUNTINGTON STATION, NY PHONE FAX CHILD SUPPORT VERIFICATION FORM TO WHOM IT MAY CONCERN, THE AGENCY/EMPLOYER OR PERSON PROVIDING INCOME MUST VERIFY THE INCOMES OF EACH ADULT TENANT APPLICANT. PARTICIPATION IN THE PROGRAM IS LIMITED TO INCOME ELIGIBLE FAMILIES AND RENT IS BASED ON A PERCENTAGE OF GROSS INCOME. PLEASE PROVIDE THE REQUESTED INFORMATION AS SOON AS POSSIBLE. BELOW IS A SIGNED AUTHORIZATION FOR RELEASE OF THIS INFORMATION TO THE HOUSING AUTHORITY. THANK YOU FOR YOUR COOPERATION. SINCERELY, THE HHA. I HEREBY RELEASE TO THE TOWN OF HUNTINGTON HOUSING AUTHORITY ALL INFORMATION RELATIVE TO MY INCOME. DOCKET #: DATE: CHILD(RENS) NAME: RESPONDENT S NAME: TENANT S NAME: SIGNATURE OF TENANT: SOCIAL SECURITY #: FOR CHILD SUPPORT ENFORCEMENT BUREAU USE ONLY GROSS AMOUNT: $ THIS AMOUNT IS PAID (CHECK ONE): WEEKLY SEMI-MONTHLY EFFECTIVE DATE: IS THE RESPONDENT CURRENTLY IN ARREARS?: YES / NO IF YES, HOW MUCH? $ BI-WEEKLY MONTHLY WORKER S SIGNATURE:

18 TOWN OF HUNTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE HUNTINGTON STATION, NY PHONE FAX VERIFICATION OF CHILDCARE EXPENSES PLEASE KNOW THAT THIS EXPENSE CAN ONLY BE CLAIMED FOR CHILDREN UNDER THE AGE OF 13. THIS FORM ALSO MUST BE NOTARIZED AND ACCOMPANIED BY PROOF OF PAYMENT (AT LEAST 3 MONEY ORDERS, CANCELLED CHECKS, OR RECEPTS FROM THE DAY CARE PROVIDER.) I, (CHILDCARE PROVIDER) WHO RESIDES AT DO HEREBY CERTIFY THAT I PROVIDE CHILDCARE FOR THE FOLLOWING CHILDREN: TOTAL HOURS PER WEEK: AMOUNT RECEIVED FOR CARE FROM THE FAMILY: $ PER WEEK. FULL-TIME SUMMER CARE OF SCHOOL AGE CHILDREN? YES/ NO (CIRCLE ONE) SIGNATURE OF CARE PROVIDER DATE SIGNED THIS DAY OF 20 IN THE PRESENCE OF. (SIGNATURE OF NOTARY) SIGNATURE OF HEAD OF HOUSEHOLD

19 TOWN OF HUNGTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE HUNTINGTON STATION, NY FAX STUDENT-ENROLLMENT VERIFICATION FORM DATE: SCHOOL NAME& ADDRESS: HOME ADDRESS: STUDENT S NAME: VERIFICATION OF STUDENT STATUS FEDERAL REGULATIONS REQUIRE THE HOUSING AUTHORITY TO VERIFY STUDENT STATUS OF HOUSEHOLD/FAMILY MEMBERS FOR THE DETERMINATION OF THE FAMILY S ELIGIBILITY FOR RENTAL ASSISTANCE. PLEASE SUPPLY THE INFORMATION REQUESTED BELOW. I HEREBY REQUEST THAT YOU FURNISH THE HOUSING AUTHORITY INFORMATION REGARDING THE STUDENT(S) LISTED ABOVE. I UNDERSTAND THAT THIS INFORMATION WILL BE KEPT CONFIDENTIAL AND USED ONLY FOR THE PROGRAM PURPOSES. -HUNTINGTON HOUSING AUTHORITY SIGNATURE OF PARENT/GUARDIAN FOR SCHOOL USE ONLY STUDENT S HOME ADDRESS: PARENT/GUARDIAN RESPONSIBLE FOR STUDENT: THIS IS TO CERTIFY THAT THE ABOVE LISTED STUDENT(S) IS ENROLLED AT THIS SCHOOL. NAME OF EDUCATIONAL INSTITUTION: AUTHORIZED SIGNATURE DATE: TITLE PHONE #:

20 TOWN OF HUNGTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE HUNTINGTON STATION, NY FAX STUDENT-ENROLLMENT VERIFICATION FORM DATE: SCHOOL NAME& ADDRESS: HOME ADDRESS: STUDENT S NAME: VERIFICATION OF STUDENT STATUS FEDERAL REGULATIONS REQUIRE THE HOUSING AUTHORITY TO VERIFY STUDENT STATUS OF HOUSEHOLD/FAMILY MEMBERS FOR THE DETERMINATION OF THE FAMILY S ELIGIBILITY FOR RENTAL ASSISTANCE. PLEASE SUPPLY THE INFORMATION REQUESTED BELOW. I HEREBY REQUEST THAT YOU FURNISH THE HOUSING AUTHORITY INFORMATION REGARDING THE STUDENT(S) LISTED ABOVE. I UNDERSTAND THAT THIS INFORMATION WILL BE KEPT CONFIDENTIAL AND USED ONLY FOR THE PROGRAM PURPOSES. -HUNTINGTON HOUSING AUTHORITY SIGNATURE OF PARENT/GUARDIAN FOR SCHOOL USE ONLY STUDENT S HOME ADDRESS: PARENT/GUARDIAN RESPONSIBLE FOR STUDENT: THIS IS TO CERTIFY THAT THE ABOVE LISTED STUDENT(S) IS ENROLLED AT THIS SCHOOL. NAME OF EDUCATIONAL INSTITUTION: AUTHORIZED SIGNATURE DATE: TITLE PHONE #:

21 TOWN OF HUNTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE HUNTINGTON STATION, NY FAX VERIFICATION OF COLLEGE ENROLLMENT FORM DATE: STUDENT S NAME: STUDENT S SSN: COLLEGE NAME: COLLEGE ADDRESS: VERIFICATION OF STUDENT STATUS FEDERAL REGULATIONS REQUIRE THE HOUSING AUTHORITY TO VERIFY STUDENT STATUS OF HOUSEHOLD/FAMILY MEMBERS FOR THE DETERMINATION OF THE FAMILY S ELIGIBILITY FOR RENTAL ASSISTANCE. PLEASE SUPPLY THE INFORMATION REQUESTED BELOW. STUDENT S SIGNATURE HEAD OF HOUSEHOLD SIGNATURE FOR COLLEGE USE ONLY THIS IS TO CERTIFY THAT THE ABOVE NAMED STUDENT IS ENROLLED AS A (CHECK ONE): FULL-TIME STUDENT PART-TIME STUDENT DATE OF ENROLLMENT: ANTICIPATED GRADUATION DATE: ASSISTANCE AND TUITION PER SEMESTER ASSISTANCE OF: $ (PLEASE LIST COST PER SEMESTER) TYPE TUITION BEFOG $ BOOKS $ G.I. BILL $ SUPPLIES $ NSDL $ EQUIPMENT $ WORK-STUDY $ TRANSPORT. $ OTHER $ OTHER $ IS THE STUDENT ENROLLED FOR SUMMER MONTHS?: YES NO NAME OF EDUCATIONAL INSTITUTION: TELEPHONE NUMBER AUTHORIZED SIGNATURE I HEREBY REQUEST THAT YOU FURNISH THE HOUSING AUTHORITY INFORMATION REGARDING THE STUDENT LISTED ABOVE.

22 TOWN OF HUNTINGTON HOUSING AUTHORITY 1A LOWNDES AVENUE HUNTINGTON STATION N.Y PHONE (631) FAX (631) FULL TIME COLLEGE STUDENT STATUS VERIFICATION Please prvide a LETTER frm the schl s REGISTRAR OFFICE indicating current F/T student status f adult husehld member. An acceptance letter, bill r schedule will NOT be cnsidered).

23

24

25 OMB N Expires 08/31/2016 U.S. Department f Husing and Urban Develpment Office f Public and Indian Husing DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS Paperwrk Reductin Ntice: Public reprting burden fr this cllectin f infrmatin is estimated t average 7 minutes per respnse. This includes the time fr respndents t read the dcument and certify, and any recrdkeeping burden. This infrmatin will be used in the prcessing f a tenancy. Respnse t this request fr infrmatin is required t receive benefits. The agency may nt cllect this infrmatin, and yu are nt required t cmplete this frm, unless it displays a currently valid OMB cntrl number. The OMB Number is , and expires 08/31/2016. NOTICE TO APPLICANTS AND PARTICIPANTS OF THE FOLLOWING HUD RENTAL ASSISTANCE PROGRAMS: Public Husing (24 CFR 960) Sectin 8 Husing Chice Vucher, including the Disaster Husing Assistance Prgram (24 CFR 982) Sectin 8 Mderate Rehabilitatin (24 CFR 882) Prject-Based Vucher (24 CFR 983) The U.S. Department f Husing and Urban Develpment maintains a natinal repsitry f debts wed t Public Husing Agencies (PHAs) r Sectin 8 landlrds and adverse infrmatin f frmer participants wh have vluntarily r invluntarily terminated participatin in ne f the abve-listed HUD rental assistance prgrams. This infrmatin is maintained within HUD s Enterprise Incme Verificatin (EIV) system, which is used by Public Husing Agencies (PHAs) and their management agents t verify emplyment and incme infrmatin f prgram participants, as well as, t reduce administrative and rental assistance payment errrs. The EIV system is designed t assist PHAs and HUD in ensuring that families are eligible t participate in HUD rental assistance prgrams and determining the crrect amunt f rental assistance a family is eligible fr. All PHAs are required t use this system in accrdance with HUD regulatins at 24 CFR HUD requires PHAs, which administers the abve-listed rental husing prgrams, t reprt certain infrmatin at the cnclusin f yur participatin in a HUD rental assistance prgram. This ntice prvides yu with infrmatin n what infrmatin the PHA is required t prvide HUD, wh will have access t this infrmatin, hw this infrmatin is used and yur rights. PHAs are required t prvide this ntice t all applicants and prgram participants and yu are required t acknwledge receipt f this ntice by signing page 2. Each adult husehld member must sign this frm. What infrmatin abut yu and yur tenancy des HUD cllect frm the PHA? The fllwing infrmatin is cllected abut each member f yur husehld (family cmpsitin): full name, date f birth, and Scial Security Number. The fllwing adverse infrmatin is cllected nce yur participatin in the husing prgram has ended, whether yu vluntarily r invluntarily mve ut f an assisted unit: 1. Amunt f any balance yu we the PHA r Sectin 8 landlrd (up t $500,000) and explanatin fr balance wed (i.e. unpaid rent, retractive rent (due t unreprted incme and/ r change in family cmpsitin) r ther charges such as damages, utility charges, etc.); and 2. Whether r nt yu have entered int a repayment agreement fr the amunt that yu we the PHA; and 3. Whether r nt yu have defaulted n a repayment agreement; and 4. Whether r nt the PHA has btained a judgment against yu; and 5. Whether r nt yu have filed fr bankruptcy; and 6. The negative reasn(s) fr yur end f participatin r any negative status (i.e., abandned unit, fraud, lease vilatins, criminal activity, etc.) as f the end f participatin date. 08/2013 Frm HUD-52675

26 OMB N Expires 08/31/ Wh will have access t the infrmatin cllected? This infrmatin will be available t HUD emplyees, PHA emplyees, and cntractrs f HUD and PHAs. Hw will this infrmatin be used? PHAs will have access t this infrmatin during the time f applicatin fr rental assistance and reexaminatin f family incme and cmpsitin fr existing participants. PHAs will be able t access this infrmatin t determine a family s suitability fr initial r cntinued rental assistance, and avid prviding limited Federal husing assistance t families wh have previusly been unable t cmply with HUD prgram requirements. If the reprted infrmatin is accurate, a PHA may terminate yur current rental assistance and deny yur future request fr HUD rental assistance, subject t PHA plicy. Hw lng is the debt wed and terminatin infrmatin maintained in EIV? Debt wed and terminatin infrmatin will be maintained in EIV fr a perid f up t ten (10) years frm the end f participatin date. What are my rights? In accrdance with the Federal Privacy Act f 1974, as amended (5 USC 552a) and HUD regulatins pertaining t its implementatin f the Federal Privacy Act f 1974 (24 CFR Part 16), yu have the fllwing rights: 1. T have access t yur recrds maintained by HUD, subject t 24 CFR Part T have an administrative review f HUD s initial denial f yur request t have access t yur recrds maintained by HUD. 3. T have incrrect infrmatin in yur recrd crrected upn written request. 4. T file an appeal request f an initial adverse determinatin n crrectin r amendment f recrd request within 30 calendar days after the issuance f the written denial. 5. T have yur recrd disclsed t a third party upn receipt f yur written and signed request. What d I d if I dispute the debt r terminatin infrmatin reprted abut me? If yu disagree with the reprted infrmatin, yu shuld cntact in writing the PHA wh has reprted this infrmatin abut yu. The PHA s name, address, and telephne numbers are listed n the Debts Owed and Terminatin Reprt. Yu have a right t request and btain a cpy f this reprt frm the PHA. Infrm the PHA why yu dispute the infrmatin and prvide any dcumentatin that supprts yur dispute. HUD's recrd retentin plicies at 24 CFR Part 908 and 24 CFR Part 982 prvide that the PHA may destry yur recrds three years frm the date yur participatin in the prgram ends. T ensure the availability f yur recrds, disputes f the riginal debt r terminatin infrmatin must be made within three years frm the end f participatin date; therwise the debt and terminatin infrmatin will be presumed crrect. Only the PHA wh reprted the adverse infrmatin abut yu can delete r crrect yur recrd. Yur filing f bankruptcy will nt result in the remval f debt wed r terminatin infrmatin frm HUD s EIV system. Hwever, if yu have included this debt in yur bankruptcy filing and/r this debt has been discharged by the bankruptcy curt, yur recrd will be updated t include the bankruptcy indicatr, when yu prvide the PHA with dcumentatin f yur bankruptcy status. The PHA will ntify yu in writing f its actin regarding yur dispute within 30 days f receiving yur written dispute. If the PHA determines that the disputed infrmatin is incrrect, the PHA will update r delete the recrd. If the PHA determines that the disputed infrmatin is crrect, the PHA will prvide an explanatin as t why the infrmatin is crrect. This Ntice was prvided by the belw-listed PHA: I hereby acknwledge that the PHA prvided me with the Debts Owed t PHAs & Terminatin Ntice: Signature Date Printed Name 08/2013 Frm HUD-52675

27 OMB N Expires 08/31/2016 U.S. Department f Husing and Urban Develpment Office f Public and Indian Husing DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS Paperwrk Reductin Ntice: Public reprting burden fr this cllectin f infrmatin is estimated t average 7 minutes per respnse. This includes the time fr respndents t read the dcument and certify, and any recrdkeeping burden. This infrmatin will be used in the prcessing f a tenancy. Respnse t this request fr infrmatin is required t receive benefits. The agency may nt cllect this infrmatin, and yu are nt required t cmplete this frm, unless it displays a currently valid OMB cntrl number. The OMB Number is , and expires 08/31/2016. NOTICE TO APPLICANTS AND PARTICIPANTS OF THE FOLLOWING HUD RENTAL ASSISTANCE PROGRAMS: Public Husing (24 CFR 960) Sectin 8 Husing Chice Vucher, including the Disaster Husing Assistance Prgram (24 CFR 982) Sectin 8 Mderate Rehabilitatin (24 CFR 882) Prject-Based Vucher (24 CFR 983) The U.S. Department f Husing and Urban Develpment maintains a natinal repsitry f debts wed t Public Husing Agencies (PHAs) r Sectin 8 landlrds and adverse infrmatin f frmer participants wh have vluntarily r invluntarily terminated participatin in ne f the abve-listed HUD rental assistance prgrams. This infrmatin is maintained within HUD s Enterprise Incme Verificatin (EIV) system, which is used by Public Husing Agencies (PHAs) and their management agents t verify emplyment and incme infrmatin f prgram participants, as well as, t reduce administrative and rental assistance payment errrs. The EIV system is designed t assist PHAs and HUD in ensuring that families are eligible t participate in HUD rental assistance prgrams and determining the crrect amunt f rental assistance a family is eligible fr. All PHAs are required t use this system in accrdance with HUD regulatins at 24 CFR HUD requires PHAs, which administers the abve-listed rental husing prgrams, t reprt certain infrmatin at the cnclusin f yur participatin in a HUD rental assistance prgram. This ntice prvides yu with infrmatin n what infrmatin the PHA is required t prvide HUD, wh will have access t this infrmatin, hw this infrmatin is used and yur rights. PHAs are required t prvide this ntice t all applicants and prgram participants and yu are required t acknwledge receipt f this ntice by signing page 2. Each adult husehld member must sign this frm. What infrmatin abut yu and yur tenancy des HUD cllect frm the PHA? The fllwing infrmatin is cllected abut each member f yur husehld (family cmpsitin): full name, date f birth, and Scial Security Number. The fllwing adverse infrmatin is cllected nce yur participatin in the husing prgram has ended, whether yu vluntarily r invluntarily mve ut f an assisted unit: 1. Amunt f any balance yu we the PHA r Sectin 8 landlrd (up t $500,000) and explanatin fr balance wed (i.e. unpaid rent, retractive rent (due t unreprted incme and/ r change in family cmpsitin) r ther charges such as damages, utility charges, etc.); and 2. Whether r nt yu have entered int a repayment agreement fr the amunt that yu we the PHA; and 3. Whether r nt yu have defaulted n a repayment agreement; and 4. Whether r nt the PHA has btained a judgment against yu; and 5. Whether r nt yu have filed fr bankruptcy; and 6. The negative reasn(s) fr yur end f participatin r any negative status (i.e., abandned unit, fraud, lease vilatins, criminal activity, etc.) as f the end f participatin date. 08/2013 Frm HUD-52675

28 OMB N Expires 08/31/ Wh will have access t the infrmatin cllected? This infrmatin will be available t HUD emplyees, PHA emplyees, and cntractrs f HUD and PHAs. Hw will this infrmatin be used? PHAs will have access t this infrmatin during the time f applicatin fr rental assistance and reexaminatin f family incme and cmpsitin fr existing participants. PHAs will be able t access this infrmatin t determine a family s suitability fr initial r cntinued rental assistance, and avid prviding limited Federal husing assistance t families wh have previusly been unable t cmply with HUD prgram requirements. If the reprted infrmatin is accurate, a PHA may terminate yur current rental assistance and deny yur future request fr HUD rental assistance, subject t PHA plicy. Hw lng is the debt wed and terminatin infrmatin maintained in EIV? Debt wed and terminatin infrmatin will be maintained in EIV fr a perid f up t ten (10) years frm the end f participatin date. What are my rights? In accrdance with the Federal Privacy Act f 1974, as amended (5 USC 552a) and HUD regulatins pertaining t its implementatin f the Federal Privacy Act f 1974 (24 CFR Part 16), yu have the fllwing rights: 1. T have access t yur recrds maintained by HUD, subject t 24 CFR Part T have an administrative review f HUD s initial denial f yur request t have access t yur recrds maintained by HUD. 3. T have incrrect infrmatin in yur recrd crrected upn written request. 4. T file an appeal request f an initial adverse determinatin n crrectin r amendment f recrd request within 30 calendar days after the issuance f the written denial. 5. T have yur recrd disclsed t a third party upn receipt f yur written and signed request. What d I d if I dispute the debt r terminatin infrmatin reprted abut me? If yu disagree with the reprted infrmatin, yu shuld cntact in writing the PHA wh has reprted this infrmatin abut yu. The PHA s name, address, and telephne numbers are listed n the Debts Owed and Terminatin Reprt. Yu have a right t request and btain a cpy f this reprt frm the PHA. Infrm the PHA why yu dispute the infrmatin and prvide any dcumentatin that supprts yur dispute. HUD's recrd retentin plicies at 24 CFR Part 908 and 24 CFR Part 982 prvide that the PHA may destry yur recrds three years frm the date yur participatin in the prgram ends. T ensure the availability f yur recrds, disputes f the riginal debt r terminatin infrmatin must be made within three years frm the end f participatin date; therwise the debt and terminatin infrmatin will be presumed crrect. Only the PHA wh reprted the adverse infrmatin abut yu can delete r crrect yur recrd. Yur filing f bankruptcy will nt result in the remval f debt wed r terminatin infrmatin frm HUD s EIV system. Hwever, if yu have included this debt in yur bankruptcy filing and/r this debt has been discharged by the bankruptcy curt, yur recrd will be updated t include the bankruptcy indicatr, when yu prvide the PHA with dcumentatin f yur bankruptcy status. The PHA will ntify yu in writing f its actin regarding yur dispute within 30 days f receiving yur written dispute. If the PHA determines that the disputed infrmatin is incrrect, the PHA will update r delete the recrd. If the PHA determines that the disputed infrmatin is crrect, the PHA will prvide an explanatin as t why the infrmatin is crrect. This Ntice was prvided by the belw-listed PHA: I hereby acknwledge that the PHA prvided me with the Debts Owed t PHAs & Terminatin Ntice: Signature Date Printed Name 08/2013 Frm HUD-52675