The Federal government provides rent subsidies for low and moderate income families that meet established program eligibility requirements. Applicants for these rent subsidies are required by Federal Statutes to make a complete disclosure of all assets and all sources of income. Failure to divulge all assets and all sources of income may result in an erroneous determination of eligibility and wrongful payment of rent subsidy. WARNING: SUBMISSION OF FALSE INFORMATION OR OMISSION OF REQUESTED INFORMATION MAY RESULT IN THE FEDERAL GOVERNMENT INITIATING CRIMINAL PROSECUTION OF EACH ADULT SIGNING THIS CERTIFICATION. SHOULD CRIMINAL ACTION COMMENCE, THIS CERTIFICATION MAY BE USED THE INSPECTOR GENERAL OR THE JUSTICE DEPARTMENT. Please carefully read the instructions and provide all requested information. IF YOU HAVE ANY QUESTIONS AS TO THE MEANING OF ANY WORDS, QUESTIONS, OR WHAT IS BEING ASKED, PLEASE ASK FOR ASSISTANCE. DO T GUESS. To be completed by management: Property Name: Building/Unit #: Tenant Name: Type of Cert.: Do you wish to make any changes or additions to the Supplement to Application for Federally Assisted Housing (persons to contact)? INCOME 1 Are you self-employed? (ex. child care income, babysitting income, business income, franchise income, gardening income, etc.) Nature of business(s): 2 Are you currently employed? If yes, how many employers? Name of employer(s): Do you receive tips? If yes, what is the average monthly amount? Do you receive a bonus or commission? If yes, how often is it paid If yes, what was the most recent amount paid 3 If you are not currently employed, do you work seasonally or less than 52 weeks in a year? If yes, how many employers? Name of employer(s): 4 Are you currently receiving unemployment benefits? If no, are you eligible for unemployment benefits? If you are eligible and not receiving benefits, are you planning to apply for unemployment benefits? If applied, on what date? 5 Did you file an income tax return for the most current tax year? 6 Are you currently receiving Workers Compensation and/or Disability benefits through employment? If no, are you eligible to receive Workers Compensation and/or Disability benefits through employment? If you are eligible, and are not receiving benefits, are you planning to apply for Workers Compensation and/or Disability benefits? If applied, on what date? SK-120 (Rev 7/6/2017) 1
7 Are you currently receiving periodic payments from any pension(s), Veterans Pension, annuities, insurance policies, retirement funds, death benefits, royalties or other periodic payments? Name of Institution(s) and Source(s): 1. 2. 3. If no, are you eligible to receive periodic payments from a pension, annuities, insurance policies, retirement funds, death benefits, royalties, or other periodic payments? If no, will you be eligible to receive periodic income from the above source within the next 12 months? 8 Are you receiving Social Security Benefits on behalf of minors or adults? Or are any minors in the family receiving Social Security benefits for their own support? Name of Family Member(s): 9 Are you receiving severance pay from your previous employer? Name of Employer(s): 10 Do you receive alimony payments? Name of Source(s): If no, are you eligible to receive alimony payments? 11 Do you receive child support payments? Name of Source(s): Do you have any legal document or any other agreement showing an Award of Child Support? If no, are you eligible to receive child support payments? 12 Do you receive cash contributions from persons that do not reside in your household? Name of Source(s): Does any person not residing in your household, or does any agency, pay for any of your bills? If yes, which bill(s) Amount of Bill 13 Do you receive Public Assistance? (ex. AFDC, DES, DPSS, Welfare Benefits, Food Stamps, Medical, CAPI, etc.) List type of benefit(s): If no, have you applied for Public Assistance? If applied, on what date? 14 Do you receive Public Assistance SPECIFICALLY DESIGNATED FOR SHELTER AND UTILITIES? SK-120 (Rev 7/6/2017) 2
15 HUD Requires answers for the following questions regarding your utilities. Do you pay a flat rate for utilities every month as part of low-income rate assistance program? If yes, what is the amount? If yes, what is the name of the program? Do you receive any utility assistance either in cash or credit from sources other than HUD? (for example, friends, relatives, California Climate Credit, Lifetime Assistance, utility related senior assistance) If no, please skip to question 16 If yes, from whom? If yes, for how many months do you receive assistance? What is the monthly amount? What are the names of your utility companies? 16 Have you applied for SSA or SSI? Do you receive Social Security payments? Do you receive Supplemental Security Income (SSI)? Do you receive disability, survivor, or death benefits for yourself or on behalf of others (ex. Dual Entitlement)? 17 Do you receive pay or allowances from a member of your family who is in the Armed Forces, whether or not that member lives in the apartment? 18 Do you receive benefits from the Veteran s Administration, GI Bill, National Guard or any other Military benefits or income? 19 Do you receive Adoption or Foster Care payments for any child or adult? 20 Do you receive any income from rental property? List address(es) of property/ies: 21 Do you receive any scholarships, grants, stipends, etc.? Name of Institution(s) and Source(s): 22 Do you receive any income not mentioned on this form and any unreported/cash tips? If yes, please indicate below: Name of Source(s) and address(es): ASSETS 1 What is your total amount of cash on hand, not currently in the bank? 2 Do you have checking accounts? Name of Institution(s) and Account Number(s): SK-120 (Rev 7/6/2017) 3 Current Balance
3 Do you have a savings account? How many Savings Accounts? Name of Institution(s) and Account Number(s): Current Balance 4 Do you receive benefits on a debit card? (example: EDD, SS/SSI, KAPI, Cash Aid, etc.) Balance on Debit Card Account: 5 Do you have any Certificate of Deposit accounts? 6 Do you have any Money Market accounts? 7 Do you have Individual Retirement Accounts (IRA), 401k, 403b, Keogh, or other Retirement Accounts? 8 Do you have a whole life insurance policy? 9 Do you have any stocks, bonds, mutual funds, Treasury Bills, etc.? 10 Do you have any revocable trusts? Name of Institution(s): Cash Value/Balance/ Int. % 11 Do you have personal property held as an investment (ex. memorabilia, gems, jewelry, etc.) or bought and sold as a source of income? If yes, please list: Cash Value/Balance/ Int. % 12 Do you own any real estate? List Address(es): Current Value SK-120 (Rev 7/6/2017) 4
Do you hold any mortgages or trust deeds? Name of Institution(s): Current Loan Balance 13 Have you sold or disposed of any asset or business in the last two (2) years? If yes, please list: Cash Value EXPENSES 1 Do you pay for child/dependent care or babysitting? Will any of these expenses be reimbursed or supplemented by an outside source? If yes, how much? Name of provider(s): Monthly Amount 2 Do you fall under one or more of the following categories: 62 years or older, disabled or handicapped? If yes, you may qualify for medical/disability allowances. Do you have medical expenses that are are not reimbursed? (Ex. Prescriptions, Insurance Premiums, Doctor s Visits, etc.) If no medical expenses, initial List source(s) of expenses: Amount Paid here (Initial) STUDENT STATUS 1 Are you a part-time or full-time student (ex. Elementary, High School, College/University, Trade School, etc.)? If (Elementary and High School excluded): Are you currently residing with your parent/guardian? What is your age? Name of Institution(s): What is your anticipated graduation date? 2 If you are a part-time or full-time student, do you receive financial support from parents or guardians, who are not residing with you? If yes, how much? 3 Do you receive any scholarships, grants, stipends, etc.? Name of Institution(s) and Source(s): Total Amount 4 Do you pay for expenses such as writing and science lab fees, student service fees, student body, student association and/or activity fees? If yes, how much? SK-120 (Rev 7/6/2017) 5
HOUSEHOLD COMPOSITION HH Mbr # Last Name, First Name Relationship to Head of Household Date of Birth Social Security Number School Name (if applicable) 1 HEAD 2 3 4 5 6 7 8 9 Are any household members currently enlisted in the U.S. Military or veterans of the U.S Military? If separated or divorced, please provide the following information and circle one: Separated / Divorced Name of spouse/ex-spouse: Do you file a joint tax return? Do you hold any joint assets with any person T residing in your household,, such as checking, savings, real estate? Do you expect any changes to the household in the next twelve (12) months? If yes, are any of the above listed person(s) in the process of: adoption pursuing custody expecting a child- estimated due date: If pursuing custody or adoption, please list name of the household member and action pursuing: 1. Are you registered on any lifetime sex offender registry? If yes, please specify the date? SK-120 (Rev 7/6/2017) 6
The Government May Use Computer Cross-Referencing For: Grant Program Allocation, Bank and Savings & Loan accounts, Interest Bearing Accounts, Certificates of Deposit, Securities and Exchange Commission for Stocks, Bonds, and Mutual Funds. MAKE ABSOLUTELY SURE THAT ALL INCOME AND ASSETS ARE INCLUDED! WARNING: FAILURE TO DIVULGE ALL SOURCES OF INCOME, ALL ASSETS, AND/OR THE SUBMISSION OF FALSE INFORMATION IS A VIOLATION OF FEDERAL STATUTE AND IS PUNISHABLE BY: 1. 10,000 FINE; 2. IMPRISONMENT FOR FIVE YEARS 3. REPAYMENT OF ALL WRONGFULLY PAID RENT SUBSIDY 4. REMOVAL FROM THE RENT SUBSIDY PROGRAM ALL FAMILY MEMBERS 18 YEARS OF AGE OR OLDER, AND THE HEAD OF HOUSEHOLD, CO-HEAD OF HOUSEHOLD, AND SPOUSE MUST SIGN INDIVIDUALLY BELOW. EACH FAMILY MEMBER BY SIGNING THIS CERTIFICATION HEREBY ATTESTS TO ITS ACCURACY AND COMPLETENESS AND UNDERSTANDS THAT ANY FALSE STATEMENT OR OMISSION OF INCOME SOURCE OR ASSET MAY RESULT IN CRIMINAL PROSECUTION. APPLICANT/RESIDENT CERTIFICATION 1. Reporting changes in Income or Household Composition I know I am required to report immediately in writing changes in cumulative household income of 200.00 or more per month. My household is also required to report any changes in the household size, when a person moves in or out of the unit. I understand the rules regarding guests/visitors and when I must report anyone who is staying with me. 2. No Duplicate Residence or Assistance I certify that the apartment will be my principal residence and that I not obtain duplicate federal housing assistance while I am in this current program. I will not live anywhere else without notifying the landlord immediately in writing. I will not sublease my assisted residence. 3. Reporting on Prior Housing Assistance I certify that I have disclosed where I received any previous federal housing assistance and whether or not any money is owed. I certify that for this previous assistance I did not commit any fraud, misrepresent any information, or vacate the unit in violation of the lease. 4. Cooperation I know I am required to cooperate in supplying all information needed to determine my eligibility, level of benefits, or verify my true circumstances. Cooperation includes attending pre-scheduled meeting and completing and signing needed forms. I understand failure or refusal to do so may result in delays, termination of assistance, or eviction. 5. Criminal and Administration Action for False Information I understand that knowingly supplying false, incomplete, or inaccurate information is punishable under federal or state criminal law. I understand that knowingly supplying false, incomplete, or inaccurate information is grounds for termination of housing assistance and/or termination of tenancy. Under penalties of perjury, I certify that the information presented on this form is true and accurate to the best of my/our knowledge. The undersigned further understands that providing false representations herein constitutes an act of fraud. False, misleading, or incomplete information will result in the denial of application or termination of the Lease agreement. Printed Name of Applicant/Tenant Signature of Applicant/Tenant Date ( ) ( ) Home Phone Number Cell Phone Number Best Time To Be Reached Printed Name of Witness (O/A Representative) Signature of Witness (O/A Representative) Date SK-120 (Rev 7/6/2017) 7