ADDRESS WHERE YOU LIVE: (Street Address) (City) (State) (Zip)

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1 Housing Choice Voucher Program Personal Declaration Any individual with a disability or other medical need who needs accommodation with respect to this form should inform the Agency. INSTRUCTIONS: Complete and sign this form in dark INK. You must fully and accurately complete all pages and sections of this form and the THDA must receive all requested verification documents or your assistance may be terminated. Write the word "NONE" if the information does not apply. All adult members in the household must sign this declaration to certify accuracy of the information reported. Please contact your rental assistance specialist by phone with any questions. If additional space is needed in any section, attach a piece of paper with the information. I. CONTACT INFORMATION ADDRESS WHERE YOU LIVE: (Street Address) (City) (State) (Zip) ADDRESS WHERE YOU RECEIVE YOUR MAIL (If different from current address) (Street Address/PO BOX) (City) (State) (Zip) Head of Household s current daytime phone number: ( ) Other Number: ( ) Emergency contact Name and Phone: ( ) address: Please list any changes that have occurred since your last recertification (i.e. job loss, person moving out): II. HOUSEHOLD COMPOSITION. Starting with the Head of the Household, list all members of the household. Use the correct legal name for each member as it appears on his/her Social Security Card or INS documents. Name Last, First Relationship to Head (Co-head, spouse, other adult/grandc hild/ son, daughter) Birthdate Gender Race Ethnicity* Disability (Yes/No) Social Security Number Head Male Male Male Male Male Male Male Non-Hispanic Non-Hispanic Non-Hispanic Non-Hispanic Non-Hispanic Non-Hispanic Non-Hispanic No No No No No No No 1. Does anyone, other than an adult who will live in the home, share custody of any of the children listed? YES NO If YES, list the name & address of the person with shared custody, and the time the child spends with the other adult (25, 50%): 2. Are any of the children listed above not birth or adopted children of an adult residing in the household? YES NO. If YES, WHO:, and does an adult residing in the household have legal custody of the child/ren? YES NO 3. Are any of the persons listed above foster children or adults? YES NO. If YES, WHO: 4. STUDENTS. List All Household Members who are enrolled in a PRIVATE school (elementary, middle, high school, college, trade school) or higher education school. Student Name(s) School Name, Address, Phone/Fax No. Full or Part Time Financial Aid? Full Time Part Time No Full Time Part Time No Full Time Part Time No ATTACH A COPY OF MOST RECENT FINANCIAL AID/TUITION STATEMENT FOR EACH COLLEGE STUDENT. 5. Amount of financial aid/assistance received: Amount of Tuition ONLY How often do you pay tuition or receive financial aid (semester, quarter, other): 6. Did a parent/guardian claim as a dependent any adult full time student listed above on the most recent tax return? Yes No Rev 05/15/2014 Equal Housing Opportunity 1

2 7. Is any adult who will reside in the home currently married? YES NO. If YES, WHO: 8. Is any adult who will reside in the home divorced? YES NO. If YES, WHO? 9. If separated or divorced, list name and address of spouse/ex-spouse: 10. If any household member is separated, is the separation a court ordered separation? YES NO. III. HOUSEHOLD EXPENSES A. GENERAL EXPENSES (Bills). List all expenses for everyone who will live in the home. ITEM MONTHLY PAYMENT PAID BY WHOM (Name)? CURRENT OR PAST DUE? Rent/ Mortgage None Electricity None Gas Heat for Home None Water for Home None Telephone None Cell Phone None Food None Cable None Internet None Car Payment (s) None Gas for Car None Car Insurance None Life Insurance None Furniture None Loan (s) None Rentals None Trash Removal None Credit Cards None Other: None Other: None BALANCE B. CHILD CARE EXPENSES Check here if you do not have Child Care Expenses and go to next section. Child s Name Child s Age Child Care Address, Phone & Fax No.; for Contact if avail. 1. Amount paid by the family is: per week OR per month 2. Amount paid by someone else: per week OR per month Name, Address, Phone & Fax No. of agency/person who pays all or part of the child care expenses: 3. The child(ren) is / are being cared for to allow to: (name of family member(s)) Check all that apply: Work full time Work part time Look for employment Go to school full time Go to school part time C. MEDICAL/DISABILITY ASSISTANCE EXPENSES Check here if the head, spouse or co-head is not at least 62 years old OR disabled and go to next section. Does anyone who will live in the home have medical expenses that are not reimbursed through another source? YES NO. Medical expenses include the following: hospital bills, medicines/prescriptions, transportation costs (cab fare, gas for car) going to and from medical treatment, medical equipment such as dialysis or oxygen machines. Family Member Name Type of Expense Monthly Amount* *Note: The expenses must be verified; in other words, you must be able to provide proof of the expense, and the expense must be paid by a member of the household. The expense may not be claimed if it is covered by insurance. Page 2 of 8- You must complete ALL pages. Rev 05/15/2014 Equal Housing Opportunity 2

3 2. Does anyone who will live in the home pay a monthly premium for health insurance (private or Medicare)? YES NO. If Yes, WHO: ; Monthly Premium(s): Who Pays Premium: Name of Insurance Company: 3. Is a live-in care provider essential to the care/ well- being of a disabled person who will live in the home? Yes No 4. Do you pay a care attendant (day care or live-in aide) for any family member(s) with disabilities that is necessary to permit that person or someone else in the family to work? Yes No Name of Family Member who is enabled to work or attend school: ; Name/Address of Person who provides services: Monthly Cost: 5. Do you pay for any equipment for any family member(s) with disabilities that is necessary to permit that person or someone else in the family to work? Yes No. If YES, please list the type of special equipment needed (wheelchair, vehicle adaptor, etc.): _ Name of family member who will be able to work: Out-of-pocket cost of the special equipment: per _ 6. Do you have a certified payee? If so list name and address of payee:. Do you pay a regular fee To the payee? ATTACH DOCUMENTATION OF THE MONTHLY FEE. IV. INCOME & ASSETS. Include all income and assets received or held by all members of the household. A. EMPLOYMENT Is anyone in the home currently employed? YES NO. If YES, please complete the following information for each person and each job. If someone works more than one job, we need the information for all jobs worked. Employment includes military, day labor, part time and temporary employment, as well as all other types of employment. If NO, go to next section. If you need to list more employers, please use an additional sheet. ATTACH A COPY OF THE MOST RECENT 4 CHECK STUBS OR A PRINT OUT OF RECENT PAY HISTORY FROM EMPLOYER. Family member name Employer Name, Address, Fax & Phone Average Hours Worked Each Week Gross Wages (per Week) Note: Provide the complete mailing address for employers, including zip code; the phone & fax number. B. FAMILY & CHILD SUPPORT Check here if no Family, Child Support or Alimony received & go to next section. 1. Does any person outside of your household or agency regularly help you with household expenses or supplies (pay your bills or give you money)? YES NO If YES, Monthly Amount: If YES, please explain: Name address, and phone number of person contributing: 2. Has anyone in the home received child support/alimony in the past 12 months: YES NO Has anyone in the home received child support in past 12 months but is not receiving it currently YES NO If yes, is this a temporary or permanent change in support? List reason for change: 3. Does anyone in the house have a court order for child support? YES NO. Is the court ordered child support paid through the Department of Human Services: YES NO If YES, enter your case member id #. 4. Is child support received directly from the absent parent or another source (such as another relative or another state)? Yes No If yes, list the name, address and phone of the absent parent or contact information for other source: 5. Complete chart for each person in the home who has received family support, child support or alimony in past 12 months: Name of person receiving family support, child support or alimony Name of child or person for whom support is being paid Name & Contact Information of person providing support Amount received Frequency of payment (weekly, etc.) Page 3 of 8- You must complete ALL pages. Rev 05/15/2014 Equal Housing Opportunity 3

4 C. OTHER INCOME Fill in ALL blanks. If the information does not apply, write "NONE" in amount received. Income Source Amount Received Family member Name(s) per month Social Security or SSI SSI VA Pension Other Pension From: TANF (Cash Assist.)/Families First Food Stamps Unemployment Self Employment/Own Business (child care, hair salon, landscape) Workmans compensation Educational Grant Job Training Program Other: 1. Are you an owner or co-owner in any business or real estate? Yes No 2. Did anyone in the household receive the Earned Income Tax Credit (EITC) last year? Yes No If yes, list household member(s) & amount of return: 3. Did anyone in the household file an income tax return last year? Yes No If Yes, which household member(s): If Yes, who was listed on the return (adults and children): D. ASSET INCOME 1. List all bank accounts (checking and savings) held by any member of the household. Mark None if you have no bank accounts. (If you need to list more than three accounts, please use an additional sheet): Family Member Acct. # & Type (checking/savings) Current Balance Bank Name & Address Attach a copy of the most recent month s checking or savings statement. 2. Does any household member have any of the following (check those that apply and enter value/balance): Money Market Acct. Trusts Stocks, Bonds, or Annuities IRA/KEOGH Retirement Account NONE If yes to any of the above, attach a copy of the most recent account statement. 3. Does any member of the household have a life insurance policy with a cash value (usually called "whole life")? YES NO If yes, please attach a copy of the insurance policy. 4. Has anyone who will live in the home received a lump sum social security payment, workman's compensation or other insurance settlement? YES NO If Yes, WHO: ; received: Amount: 5. Has anyone who will live in the home received income from a lottery or inheritance? YES NO If Yes, WHO: ; received: Amount: Page 4 of 8- You must complete ALL pages. Rev 05/15/2014 Equal Housing Opportunity 4

5 6. Does anyone in the household own or have any interest in any land, property, houses, mobile homes, lots, acreage, or other real property? YES NO If YES, describe? 7. Has anyone in the household sold or given away any real property or any other asset within the last two years? YES NO If YES, what? Was it sold or given away? To Whom? Fair Market Value? Amount received, if sold? 8. Does anyone in the household have savings/cash at home or in a safety box? YES NO If YES, who? How Much?: 9. Is your name listed as owner or co-owner on any vehicle registration? YES NO If YES, list model, year, and license plate number for each vehicle (attach extra sheet if necessary): V. CRIMINAL BACKGROUND INFORMATION 1. Has any adult who will live in the home been arrested for any type of crime (misdemeanor or felony) in the past year? YES NO. If YES, WHO of arrest Criminal charge: City/State where arrest took place_ 2. Has any adult who will live in the home been convicted pled guilty, or pled no contest of any type of crime (misdemeanor or felony) in the past 3 years? YES NO. If YES, WHO: (s) of conviction(s) Criminal charge(s): City/State where arrest(s) took place_ 3. Is anyone who will live in the home subject to a lifetime registration requirement under a State sex offender program? YES NO, If YES, Who? Where? of Conviction? 4. Has anyone who will live in the home been convicted of the production of methamphetamines on the premises of public or assisted housing? YES NO. If YES, Who? Where? of arrest/conviction: VI. FAMILY SELF SUFFICIENCY Are you interested in participating in THDA s Family Self Sufficiency Program? In this program, THDA will help you to locate the resources you need (education, child care) to secure employment and become self-sufficient. Yes No VII. CERTIFICATION We, hereby, swear and attest that all of the above information is true and complete. We understand that all adult household members are responsible for providing true and complete information and for reporting changes in a timely manner. We also understand that rental assistance may be terminated for the entire household if any one of us fails to supply true and complete information. We understand that we must report, in writing, to the Section 8 office the following changes within 30 days of the change: anyone starting to work (full or part time), any change in the type or source of income, any increase or decrease in income, and the receipt of any addition to assets. We understand any change in family composition (persons moving into or out of the home) must be reported within 30 days and that we must request, in writing, approval from THDA and the landlord before any new members move into the household. Note: You are required to report any person staying in the unit if they stay with you more than thirty (30) days annually (whether consecutive or not). By signing below, all adults certify the following forms were received with this Personal Declaration, and all adults have reviewed and understand each of the forms: GROUNDS FOR DENIAL/TERMINATION/FAMILY RESPONSIBILITIES; NOTICE OF PORTABILITY/RELOCATION REQUIREMENTS; MINIMUM RENT EXCEPTION NOTICE; FAIR HOUSING DISCRIMINATION COMPLAINT FORM; FAIR HOUSING INFORMATION & FSS & HOMEOWNERSHIP PROGRAM INFORMATION. If you have questions about any form, please contact the THDA office. SIGNATURE OF HEAD DATE SIGNATURE OTHER ADULT DATE SIGNATURE 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 U.S. DEPARTMENT OR AGENCY. TITLE 13, PUBLIC PLANNING AND HOUSING, CHAPTER 23, SECTION 133 OF THE TENNESSEE CODE ANNOTATED STATES THAT IT IS UNLAWFUL FOR ANY PERSON TO KNOWINGLY MAKE, UTTER, OR PUBLISH A FALSE STATEMENT OF SUBSTANCE OR AID OR ABET ANOTHER PERSON IN MAKING, UTTERING, OR PUBLISHING A FALSE STATEMENT OF SUBSTANCE FOR THE PURPOSE OF INFLUENCING THE AGENT TO ALLOW PARTICIPATION IN ANY OF ITS PROGRAMS. CLASS E FELONY THDA Use Only: The form was not fully completed. The head of household was contacted on to receive the necessary information. In the areas where information was collected by phone, I have initialed the information as representing the verbal answer provided by the head of household on the date stated above. THDA Staff Member Name Rev 05/15/2014 Equal Housing Opportunity 5

6 AUTHORIZATION FOR THE RELEASE OF INFORMATION All adult family members must read and sign this form. Authority & Purpose: The law (42 U.S.C. 3544) requires participants in the Housing Choice Voucher Program to sign a consent form authorizing HUD and your local housing authority, Tennessee Housing Development Agency (THDA) to obtain independent verification of income information. By signing this consent form, you are authorizing HUD and THDA to request income information from the sources listed on the form. HUD and THDA need this information to verify your household s income, in order to ensure that you are eligible for assisted housing benefits and that these benefits are set at the correct level. HUD and THDA may participate in computer matching programs with some of these sources in order to verify your eligibility and level of benefits. Use of the Income Information to be Obtained: HUD and THDA are required to protect the information it obtains in accordance with the Privacy Act of 1974, U.S.C. 552a. THDA is required to protect the information under any State privacy laws. HUD and THDA employees may be subject to penalties for unauthorized disclosures or improper use of the income information that is obtained based on the consent form. Private owners may not request or receive information authorized by this form. Who Must Sign the Consent Form: Each member of your household who is 18 years of age or older must sign the consent form. Additional signatures must be obtained from new adult members joining the household or whenever members of the household become 18 years of age. Sources of Information to be Obtained: Child support, Child Care Expenses, Disability Status, Disability Assistance Expenses, Educational Grants & Income, Federal, State, Tribal or Local Benefits (including TANF and Food Stamps), Household Composition, Identity and Marital Status, Medical Expenses, Utility Payment History Individuals or organizations that may release information: Child Support Enforcement Agencies, Educational Institutions, TANF Agencies, Public Utility Companies, and individual providers of the following: Alimony & Child Support, Child Care, Disability Assistance Equipment or Services, Medical Care or Equipment. Consent: I consent to allow HUD or THDA to request and obtain information from the sources listed on this form for the purpose of verifying my eligibility and level of benefits under HUD s assisted housing programs. I understand that THDA must independently verify the information received under this consent form, whether I actually had access to the funds and when the funds were received, before using the information to deny, reduce or terminate assistance. In addition, I must be given the opportunity to contest those determinations. This consent form expires 15 months after signed. Head of Household Spouse or Co-Head Rev 05/15/2014 Equal Housing Opportunity 6

7 Authorization for the Release of Information/ Privacy Act Notice to the U.S. Department of Housing and Urban Development (HUD) and the Housing Agency/Authority (HA) U.S. Department of Housing and Urban Development Office of Public and Indian Housing PHA requesting release of information (cross out space if none) (Full address, name of contact person, and date): Tennessee Housing Development Agency IHA requesting release of information: (Cross out space if none) (Full address, name of contact person, and date): N/A Authority: Section 904 of the Stewart B. McKinney Homeless Assistance Amendments Act of 1988, as amended by Section 903of the Housing and Community Development Act of 1992 and Section 3003 of the Omnibus Budget Reconciliation Act of This law is found at 42 U.S.C This law requires that you sign a consent form authorizing: (1) HUD and the Housing Agency/Authority (HA) to request verification of salary and wages from current or previous employers; (2) HUD and the HA to request wage and unemployment compensation claim information from the state agency responsible for keeping that information; (3) HUD to request certain tax return information from the U.S. Social Security Administration and the U.S. Internal Revenue Service. The law also requires independent verification of income information. Therefore, HUD or the HA may request information from financial institutions to verify your eligibility and level of benefits. Purpose: In signing this consent form, you are authorizing HUD and the above-named HA to request income information from the sources listed on the form. HUD and the HA need this information to verify your household s income, in order to ensure that you are eligible for assisted housing benefits and that these benefits are set at the correct level. HUD and the HA may participate in computer matching programs with these sources in order to verify your eligibility and level of benefits. Uses of Information to be Obtained: HUD is required to protect the income information it obtains in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. HUD may disclose information (other than tax return information) for certain routine uses, such as to other government agencies for law enforcement purposes, to Federal agencies for employment suitability purposes and to Has for the purpose of determining housing assistance. The HA is also required to protect the income information it obtains in accordance with any applicable State privacy law. HUD and HA employees may be subject to penalties for unauthorized disclosures or improper uses of the income information that is obtained based on the consent form. Private owners may not request or receive information authorized by this form. Who Must Sign the Consent Form: Each member of your household who is 18 years of age or older must sign the consent form. Additional signatures must be obtained from new adult members joining the household or whenever members of the household become 18 years of age. Persons who apply for or receive assistance under the following programs are required to sign this consent form: PHA-owned rental public housing Turnkey III Homeownership Opportunities Mutual Help Homeownership Opportunity Section 23 and 19(c) leased housing Section 23 Housing Assistance Payments HA-owned rental Indian housing Section 8 Rental Certificate Section 8 Rental Voucher Section 8 Moderate Rehabilitation Failure to Sign Consent Form: Your failure to sign the consent form may result in the denial of eligibility or termination of assisted housing benefits, or both. Denial of eligibility or termination of benefits is subject to the HA s grievance procedures and Section 8 informal hearing procedures. Sources of Information to be Obtained State Wage Information Collection Agencies. (This consent is limited to wages and unemployment compensation I have received during period(s) within the last 5 years when I have received assisted housing benefits.) U.S. Social Security Administration (HUD only) (This consent is limited to the wage and self-employment information and payments of retirement income as referenced at Section 6103(l)(7)(A) of the Internal Revenue Code.) U.S. Internal Revenue Service (HUD only) (This consent is limited to unearned income [i.e., interest and dividends].) Information may also be obtained directly from: (a) current and former employers concerning salary and wages and (b) financial institutions concerning unearned income (i.e., interest and dividends). I understand that income information obtained from these sources will be used to verify information that I provide in determining eligibility for assisted housing programs and the level of benefits. Therefore, this consent form only authorizes release directly from employers and financial institutions of information regarding any period(s) within the last 5 years when I have received assisted housing benefits. Original is retained by the requesting organization. ref. Handbooks , , & form HUD-9886 (7/94) Rev 05/15/2014 Equal Housing Opportunity 7

8 Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form for the purpose of verifying my eligibility and level of benefits under HUD s assisted housing programs. I understand that HAs that receive income information under this consent form cannot use it to deny, reduce or terminate assistance without first independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In addition, I must be given the opportunity to contest those determinations. This consent form expires 15 months after signed. Signatures: Head of Household Social Security Number (if any) of Head of Household Other Family Member over age 18 Spouse Other Family Member over age 18 Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937 (42 U.S.C et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair Housing Act (42 U.S.C ). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and participants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay toward rent and utilities. Other Uses: HUD uses your 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 you provide. 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 HA, including all Social Security Numbers you, and all other household members age six years and older, have and use. Giving the Social Security Numbers of all household members six 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. Penalties for Misusing this Consent: HUD, the HA and any owner (or any employee of HUD, the HA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on the form HUD 9886 is restricted to the purposes cited on the form HUD Any person who knowingly or willfully 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, the HA or the owner responsible for the unauthorized disclosure or improper use. Original is retained by the requesting organization. ref. Handbooks , , & form HUD-9886 (7/94) Rev 05/15/2014 Equal Housing Opportunity 8