COLE MILL PLACE APARTMENTS 1904 Cole Mill Road #201 Durham, North Carolina 27712 (919) 886-4130 (919) 493-1506 (FAX) www.housingfornewhope.org www.facebook.com/housingfornewhope Managed by: Allenton Management, 3500 Westgate Dr., Suite #901, Durham, NC 27707 Residential Rental Application Supplemental Information Your application for Cole Mill Place Apartments has TWO PARTS: 1) This Supplemental Information form. One form is required per application. 2) The attached Residential Rental Application form(s). A separate form is required for each adult member of the household. Application fees are not required. Your completed application can be sent by email to matts@allenton.com, or mailed or delivered to Allenton Management at the address shown above. You must submit all parts of your application before the review of your application can begin. Your application must be reviewed and determined to be complete before you can be placed on a waiting list for an available apartment. All information provided in your application will be verified as accurate and complete. You will be responsible for providing additional information as needed to properly process your application and verify your eligibility. IMPORTANT NOTICE: Your qualification for housing at Cole Mill Place Apartments depends in part on your household income. You may not be eligible for this housing. Before you submit any application forms, first check your income eligibility: 1) Determine your annual household income from all sources. Include earned income for all members of the household age 18 or older, and include unearned income (such as grants or benefits received) for all members of the household including minors. 2) Make sure your annual household income is not more than the maximum amount allowed at entry for the size of your household: MAXIMUM ANNUAL HOUSEHOLD INCOME Family size 1 2 3 4 5 6 2-bedroom $27,500 $30,950 $34,350 3-bedroom $30,950 $34,350 $37,100 $39,850 WARNING: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government.
All household members age 18 or older must sign the following statement: My authorization for release of any information needed to verify the information provided in this Supplemental Information form is provided in the attached HOME Program Eligibility Release Form. I understand that all questions answered Yes in the following sections will be verified as complete and accurate through appropriate third-party sources, and it will be my responsibility to provide additional information as requested to properly process this application and verify eligibility. I understand that this may include, as applicable, names, addresses, phone and FAX numbers, account numbers and any other documents and information as necessary to expedite the process. Signature Signature Signature Signature Date Date Date Date HOUSEHOLD INFORMATION Do you expect the number of household members to change in the next 12 months? Will any member of the household live in the unit less than 100% of the time? Is any member of the household a full-time student? Would any member of the household benefit from an accessible unit? Will any member of the household require a live-in care attendant? Name of live-in care attendant: Relationship (if any): Have you ever lived at any other property managed by Housing for New Hope or Allenton Management?
INCOME INFORMATION Earned income must be reported for any member of the household age 18 or older. Unearned income (such as grants or benefits received) must be reported for all members of the household including minors. Does any member of the household receive or expect to receive income from any of the following sources in the next 12 months? Check Yes or No for each source of income: SOURCE OF INCOME Please list Employment Information on the Residential Rental Application form(s). Include hourly wages, salaries, overtime, tips, bonuses, commissions and any payments received in cash. Regular pay as a member of the Armed Forces? Unemployment benefits or worker's compensation? Public Assistance, General Relief or Temporary Aid to Needy families (TANF)? Child support or spousal support (alimony) (must report courtordered support whether or not it is received unless legal action has been taken to remedy, and support that is not court-ordered but received directly from the payer)? If Yes, how is the support received? (check all that apply) support enforcement agency HEAD OF HOUSEHOLD ANY OTHER OCCUPANTS Name of agency: Name of court: Name of person: Explain: If money is not actually being received, are you taking legal Explain: Social Security, SSI or any other payments from the Social Security Administration? Regular payments from a pension, retirement benefit, annuities or Veteran's benefits? Regular payments from a severance package? Regular payments from any type of settlement (such as insurance settlements)? Disability, death benefits or life insurance dividends? Regular gifts or payments from anyone outside of the household (including anyone supplementing your income or paying any of your bills)? Educational grants, scholarships, or other student benefits? Regular payments from inheritances or lottery winnings? Regular payments from rental property or other types of real estate transactions? Any other source of income not listed above? Yes No
INCOME INFORMATION (CONT D) For each Yes response above, please provide the following information: HOUSEHOLD MEMBER NAME SOURCE OF INCOME (Company/office, address, name of contact person, phone, FAX) GROSS AMOUNT (before taxes) per wk, mo, yr, etc. Do you expect any member of the household to have a change in income in the next 12 months? Is any adult member of the household claiming zero income?
ASSET INFORMATION An asset is defined as any lump sum of value held in your own name and to which you currently have access. Assets held by any member of the household including minors must be reported. Does any member of the household have any of the following types of assets? Check Yes or No for each type of asset: TYPE OF ASSET Checking or savings accounts? CDs, money market accounts or treasury bills? Stocks, bonds or securities? Trust funds? HEAD OF HOUSEHOLD o ANY OTHER OCCUPANTS Pension, IRA, 401(k), 403(b), KEOUGH or other retirement accounts? Cash on hand? Surrender value of a whole life, universal life or endowment insurance policy which is available to the policy holder before death? Real estate, rental property, land contract/contract for deeds or other real estate holdings (including a personal residence, mobile home, vacant land, farm, vacation home or commercial property)? Personal property as an investment (including paintings, coin or stamp collections, artwork collections, show cars and antiques, but not including personal belongings such as your car, furniture or clothing)? Do you have a safe deposit box containing items with monetary value? Please list personal vehicle information on the Residential Rental Application form(s). Include all vehicles owned by any member of the household.
ASSET INFORMATION (CONT D) For each Yes response above, please provide the following information, including annual interest rates, dividend payments and/or any other income derived from the asset(s): HOUSEHOLD MEMBER NAME TYPE OF ASSET (Company/office, address, name of contact person, phone, FAX) VALUE OF ASSET and income derived from asset Has any member of the household sold or given away any asset(s) for less than fair market value within the past 2 years? If Yes, please identify the household member, describe the asset(s) and the amount received:
TENANT SELECTION PLAN (Effective June 1, 2012) APPLICATION PROCESSING General Completed applications are accepted on a first-come, first-served basis. The application must be completed in full, dated and signed, and delivered with all required attachments to Allenton Management. Provided all application documents have been properly completed and signed, the property manager will note on the application the date and time the application is received. Preliminary Eligibility Upon receipt of an application, the property manager will review information provided by the applicant to confirm that the application is complete and to confirm preliminary eligibility based on the information provided (i.e., age, income limits, family composition, student status, citizenship, etc.). When this review is complete, eligible applicants will be notified that they meet preliminary eligibility requirements, based on and subject to verification of the information provided; the applicant is also advised that their application will go forward with processing (or will be placed on the waiting list if there are no current vacancies). If ineligible, the applicant will be notified of the reason(s) for ineligibility. Waiting List and Processing The application will be placed on a waiting list according to the time and date the completed application is received by the property manager. Whenever an apartment is available for occupancy, the property manager will call applicants on the waiting list in order to confirm continued interest, and then process the applications (i.e., criminal and credit checks, rental history, employment and income verifications, etc.). Applicants will be notified in writing if processing reveals any disqualifying criminal, credit or rental history, including the reason(s) for denial of the application and advice about applicant s right to written appeal within 14 days of the denial. On an ongoing basis, the property manager will contact all applicants on the waiting list by mail every 90 days to confirm continued interest in housing. Applicant will be removed from the waiting list if a reply postcard is not returned by the date requested. Final Approval Upon favorable completion of all verifications and background checks, the property manager will qualify the application. The applicant will be notified of the approval and asked to contact the property manager to arrange for occupancy. Nondiscrimination Housing for New Hope is unconditionally committed to equal opportunity and nondiscrimination. Housing for New Hope s programs are offered to all persons regardless of race, color, religion, gender, family status, sexual orientation, disability or national origin.
OCCUPANCY STANDARD Number of Bedrooms Minimum Number of Occupants 2 2 4 3 3 6 Maximum Number of Occupants SCREENING GUIDELINES General The application will be denied for: Falsification of application Incomplete application Failure to provide additional information when requested by the property manager for application processing. Criminal The application will be denied if the report demonstrates that the criminal history of any member of the household may interfere with the health, safety or right to peaceful enjoyment of the premises by other residents, or if any member of the household has been convicted of any of the following (misdemeanor traffic violations are excluded): Credit Drug related criminal conviction within the last five (5) years Violent criminal activity within the last seven (7) years Name/DOB matches in registered sex offender database Name/DOB matches on the OFAC (Office of Foreign Assets Control) watch list Other criminal activity that would interfere with 1) the health, safety, or right to peaceful enjoyment of the premises by other residents, or 2) any employee or contractor working on the property History of habitual criminal activity including misdemeanors The credit report must demonstrate that financial obligations are paid as agreed. The application will be denied if the report demonstrates unfavorable credit history without efforts to address problems. Student loans and medical debts are excused if other items are in order. Unfavorable credit history is demonstrated by any of the following: Landlord collections or utility collections within the last two (2) years (can be excused with written proof that any outstanding balance has been paid in full) Credit score less than 500 Any legal items less than three (3) years old (including tax lien, repossession or other public records) Other names associated with Social Security Number, or a failed Social Security Number fraud analysis Verified eviction records within the last three (3) years (including judgments and dismissals, particularly if a habitual pattern is shown) Bankruptcy less than three (3) years old (unless discharged or good credit established since)
Landlord Reference The application will be denied if applicant has been evicted for nonpayment of rent, damages or material noncompliance, or if applicant owes past due funds to a previous landlord. Unsatisfactory rental history is demonstrated by any of the following: Poor rental history profile, verified by previous landlord as to any member of the household, including i) late payment or non- payment of rent, ii) a history of violence to persons or property, iii) a history of poor or unsanitary housekeeping, or iv) a history of drug related activity History of unruly or destructive behavior by any member of the household Other demonstrated inability to live independently Requests for reasonable accommodation and/or modification of an apartment unit, and other accommodations Disabled or handicapped persons who require special physical arrangements, prospective applicants who believe they may not meet minimum admission criteria, or persons who believe their application was denied due to past history may request reasonable accommodation and/or reasonable modification. Additional information on reasonable accommodation and/or modification requests is available on request. Whenever a written request for reasonable accommodation and/or modification is received, the property manager will evaluate the request and provide a written response within ten (10) business days.
HOME Program Eligibility Release Form Organization requesting release of information: Cole Mill Place Apartments Attn: HNH Property Manager 1904 Cole Mill Road #201 Durham, North Carolina 27712 Phone (919) 885-4750 FAX (919) 237-9273 Purpose: Your signature on this HOME Program Eligibility Release Form, and the signatures of each member of your household who is 18 years of age or older, authorizes the above-named organization to obtain information from a third party relative to your eligibility and continued participation in the: HOME Rental Rehabilitation Program Privacy Act Notice Statement: The Department of Housing and Urban Development (HUD) is requiring the collection of the information derived from this form to determine an applicant s eligibility in a HOME Program and the amount of assistance necessary using HOME funds. This information will be used to establish level of benefit on the HOME Program; to protect the Government s financial interest; and to verify the accuracy of the information furnished. It may be released to appropriate Federal, State, and local agencies when relevant, to civil, criminal, or regulatory investigators, and to prosecutors. Failure to provide any information may result in a delay or rejection of your eligibility approval. The Department is authorized to ask for this information by the National Affordable Housing Act of 1990. Instructions: Each adult member of the household must sign a HOME Program Eligibility Release Form prior to the receipt of benefit and on an annual basis to establish continued eligibility. Additional signatures must be obtained from new adult members whenever they join the household or whenever members of the household become 18 years of age. NOTE: THIS GENERAL CONSENT MAY NOT BE USED TO REQUEST A COPY OF A TAX RETURN. IF A COPY OF A TAX RETURN IS NEEDED, IRS FORM 4506, REQUEST FOR COPY OF TAX FORM MUST BE PREPARED AND SIGNED SEPARATELY. Information Covered: Inquiries may be made about items initialed by applicant/tenant: Income (all sources) Assets (all sources) Other Other Other Verification Required Initials Authorization: I authorize the above-named organization and HUD to obtain information about me and my household that is pertinent to eligibility for participation in the HOME Program. I acknowledge that: (1) A photocopy of this form is as valid as the original. (2) I have the right to review the file and the information received using this form (with a person of my choosing to accompany me). (3) I have the right to copy information from this file and to request correction of information I believe inaccurate. (4) All adult household members will sign this form and cooperate with the owner in this process. Head of Household Signature, Printed Name, and Date: Family Member HEAD Other Adult Member of the Household Signature, Printed Name, and Date: Family Member #2 X Other Adult Member of the Household Signature, Printed Name, and Date: Family Member #3 X Other Adult Member of the Household Signature, Printed Name, and Date: Family Member #4 X X
COLE MILL PLACE APARTMENTS 1904 Cole Mill Road #201 Durham, North Carolina 27712 (919) 886-4130 (919) 493-1506 (FAX) www.housingfornewhope.org www.facebook.com/housingfornewhope Managed by: Allenton Management, 3500 Westgate Dr., Suite #901, Durham, NC 27707 Residential Rental Application Supplemental Information Your application for Cole Mill Place Apartments has TWO PARTS: 1) This Supplemental Information form. One form is required per application. 2) The attached Residential Rental Application form(s). A separate form is required for each adult member of the household. Application fees are not required. Your completed application can be sent by email to matts@allenton.com, or mailed or delivered to Allenton Management at the address shown above. You must submit all parts of your application before the review of your application can begin. Your application must be reviewed and determined to be complete before you can be placed on a waiting list for an available apartment. All information provided in your application will be verified as accurate and complete. You will be responsible for providing additional information as needed to properly process your application and verify your eligibility. IMPORTANT NOTICE: Your qualification for housing at Cole Mill Place Apartments depends in part on your household income. You may not be eligible for this housing. Before you submit any application forms, first check your income eligibility: 1) Determine your annual household income from all sources. Include earned income for all members of the household age 18 or older, and include unearned income (such as grants or benefits received) for all members of the household including minors. 2) Make sure your annual household income is not more than the maximum amount allowed at entry for the size of your household: MAXIMUM ANNUAL HOUSEHOLD INCOME Family size 1 2 3 4 5 6 2-bedroom $27,500 $30,950 $34,350 3-bedroom $30,950 $34,350 $37,100 $39,850 WARNING: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government.
All household members age 18 or older must sign the following statement: My authorization for release of any information needed to verify the information provided in this Supplemental Information form is provided in the attached HOME Program Eligibility Release Form. I understand that all questions answered Yes in the following sections will be verified as complete and accurate through appropriate third-party sources, and it will be my responsibility to provide additional information as requested to properly process this application and verify eligibility. I understand that this may include, as applicable, names, addresses, phone and FAX numbers, account numbers and any other documents and information as necessary to expedite the process. Signature Signature Signature Signature Date Date Date Date HOUSEHOLD INFORMATION Do you expect the number of household members to change in the next 12 months? Will any member of the household live in the unit less than 100% of the time? Is any member of the household a full-time student? Would any member of the household benefit from an accessible unit? Will any member of the household require a live-in care attendant? Name of live-in care attendant: Relationship (if any): Have you ever lived at any other property managed by Housing for New Hope or Allenton Management?
INCOME INFORMATION Earned income must be reported for any member of the household age 18 or older. Unearned income (such as grants or benefits received) must be reported for all members of the household including minors. Does any member of the household receive or expect to receive income from any of the following sources in the next 12 months? Check Yes or No for each source of income: SOURCE OF INCOME Please list Employment Information on the Residential Rental Application form(s). Include hourly wages, salaries, overtime, tips, bonuses, commissions and any payments received in cash. Regular pay as a member of the Armed Forces? Unemployment benefits or worker's compensation? Public Assistance, General Relief or Temporary Aid to Needy families (TANF)? Child support or spousal support (alimony) (must report courtordered support whether or not it is received unless legal action has been taken to remedy, and support that is not court-ordered but received directly from the payer)? If Yes, how is the support received? (check all that apply) support enforcement agency HEAD OF HOUSEHOLD ANY OTHER OCCUPANTS Name of agency: Name of court: Name of person: Explain: If money is not actually being received, are you taking legal Explain: Social Security, SSI or any other payments from the Social Security Administration? Regular payments from a pension, retirement benefit, annuities or Veteran's benefits? Regular payments from a severance package? Regular payments from any type of settlement (such as insurance settlements)? Disability, death benefits or life insurance dividends? Regular gifts or payments from anyone outside of the household (including anyone supplementing your income or paying any of your bills)? Educational grants, scholarships, or other student benefits? Regular payments from inheritances or lottery winnings? Regular payments from rental property or other types of real estate transactions? Any other source of income not listed above? Yes No
INCOME INFORMATION (CONT D) For each Yes response above, please provide the following information: HOUSEHOLD MEMBER NAME SOURCE OF INCOME (Company/office, address, name of contact person, phone, FAX) GROSS AMOUNT (before taxes) per wk, mo, yr, etc. Do you expect any member of the household to have a change in income in the next 12 months? Is any adult member of the household claiming zero income?
ASSET INFORMATION An asset is defined as any lump sum of value held in your own name and to which you currently have access. Assets held by any member of the household including minors must be reported. Does any member of the household have any of the following types of assets? Check Yes or No for each type of asset: TYPE OF ASSET Checking or savings accounts? CDs, money market accounts or treasury bills? Stocks, bonds or securities? Trust funds? HEAD OF HOUSEHOLD o ANY OTHER OCCUPANTS Pension, IRA, 401(k), 403(b), KEOUGH or other retirement accounts? Cash on hand? Surrender value of a whole life, universal life or endowment insurance policy which is available to the policy holder before death? Real estate, rental property, land contract/contract for deeds or other real estate holdings (including a personal residence, mobile home, vacant land, farm, vacation home or commercial property)? Personal property as an investment (including paintings, coin or stamp collections, artwork collections, show cars and antiques, but not including personal belongings such as your car, furniture or clothing)? Do you have a safe deposit box containing items with monetary value? Please list personal vehicle information on the Residential Rental Application form(s). Include all vehicles owned by any member of the household.
ASSET INFORMATION (CONT D) For each Yes response above, please provide the following information, including annual interest rates, dividend payments and/or any other income derived from the asset(s): HOUSEHOLD MEMBER NAME TYPE OF ASSET (Company/office, address, name of contact person, phone, FAX) VALUE OF ASSET and income derived from asset Has any member of the household sold or given away any asset(s) for less than fair market value within the past 2 years? If Yes, please identify the household member, describe the asset(s) and the amount received:
TENANT SELECTION PLAN (Effective June 1, 2012) APPLICATION PROCESSING General Completed applications are accepted on a first-come, first-served basis. The application must be completed in full, dated and signed, and delivered with all required attachments to Allenton Management. Provided all application documents have been properly completed and signed, the property manager will note on the application the date and time the application is received. Preliminary Eligibility Upon receipt of an application, the property manager will review information provided by the applicant to confirm that the application is complete and to confirm preliminary eligibility based on the information provided (i.e., age, income limits, family composition, student status, citizenship, etc.). When this review is complete, eligible applicants will be notified that they meet preliminary eligibility requirements, based on and subject to verification of the information provided; the applicant is also advised that their application will go forward with processing (or will be placed on the waiting list if there are no current vacancies). If ineligible, the applicant will be notified of the reason(s) for ineligibility. Waiting List and Processing The application will be placed on a waiting list according to the time and date the completed application is received by the property manager. Whenever an apartment is available for occupancy, the property manager will call applicants on the waiting list in order to confirm continued interest, and then process the applications (i.e., criminal and credit checks, rental history, employment and income verifications, etc.). Applicants will be notified in writing if processing reveals any disqualifying criminal, credit or rental history, including the reason(s) for denial of the application and advice about applicant s right to written appeal within 14 days of the denial. On an ongoing basis, the property manager will contact all applicants on the waiting list by mail every 90 days to confirm continued interest in housing. Applicant will be removed from the waiting list if a reply postcard is not returned by the date requested. Final Approval Upon favorable completion of all verifications and background checks, the property manager will qualify the application. The applicant will be notified of the approval and asked to contact the property manager to arrange for occupancy. Nondiscrimination Housing for New Hope is unconditionally committed to equal opportunity and nondiscrimination. Housing for New Hope s programs are offered to all persons regardless of race, color, religion, gender, family status, sexual orientation, disability or national origin.
OCCUPANCY STANDARD Number of Bedrooms Minimum Number of Occupants 2 2 4 3 3 6 Maximum Number of Occupants SCREENING GUIDELINES General The application will be denied for: Falsification of application Incomplete application Failure to provide additional information when requested by the property manager for application processing. Criminal The application will be denied if the report demonstrates that the criminal history of any member of the household may interfere with the health, safety or right to peaceful enjoyment of the premises by other residents, or if any member of the household has been convicted of any of the following (misdemeanor traffic violations are excluded): Credit Drug related criminal conviction within the last five (5) years Violent criminal activity within the last seven (7) years Name/DOB matches in registered sex offender database Name/DOB matches on the OFAC (Office of Foreign Assets Control) watch list Other criminal activity that would interfere with 1) the health, safety, or right to peaceful enjoyment of the premises by other residents, or 2) any employee or contractor working on the property History of habitual criminal activity including misdemeanors The credit report must demonstrate that financial obligations are paid as agreed. The application will be denied if the report demonstrates unfavorable credit history without efforts to address problems. Student loans and medical debts are excused if other items are in order. Unfavorable credit history is demonstrated by any of the following: Landlord collections or utility collections within the last two (2) years (can be excused with written proof that any outstanding balance has been paid in full) Credit score less than 500 Any legal items less than three (3) years old (including tax lien, repossession or other public records) Other names associated with Social Security Number, or a failed Social Security Number fraud analysis Verified eviction records within the last three (3) years (including judgments and dismissals, particularly if a habitual pattern is shown) Bankruptcy less than three (3) years old (unless discharged or good credit established since)
Landlord Reference The application will be denied if applicant has been evicted for nonpayment of rent, damages or material noncompliance, or if applicant owes past due funds to a previous landlord. Unsatisfactory rental history is demonstrated by any of the following: Poor rental history profile, verified by previous landlord as to any member of the household, including i) late payment or non- payment of rent, ii) a history of violence to persons or property, iii) a history of poor or unsanitary housekeeping, or iv) a history of drug related activity History of unruly or destructive behavior by any member of the household Other demonstrated inability to live independently Requests for reasonable accommodation and/or modification of an apartment unit, and other accommodations Disabled or handicapped persons who require special physical arrangements, prospective applicants who believe they may not meet minimum admission criteria, or persons who believe their application was denied due to past history may request reasonable accommodation and/or reasonable modification. Additional information on reasonable accommodation and/or modification requests is available on request. Whenever a written request for reasonable accommodation and/or modification is received, the property manager will evaluate the request and provide a written response within ten (10) business days.
HOME Program Eligibility Release Form Organization requesting release of information: Cole Mill Place Apartments Attn: HNH Property Manager 1904 Cole Mill Road #201 Durham, North Carolina 27712 Phone (919) 885-4750 FAX (919) 237-9273 Purpose: Your signature on this HOME Program Eligibility Release Form, and the signatures of each member of your household who is 18 years of age or older, authorizes the above-named organization to obtain information from a third party relative to your eligibility and continued participation in the: HOME Rental Rehabilitation Program Privacy Act Notice Statement: The Department of Housing and Urban Development (HUD) is requiring the collection of the information derived from this form to determine an applicant s eligibility in a HOME Program and the amount of assistance necessary using HOME funds. This information will be used to establish level of benefit on the HOME Program; to protect the Government s financial interest; and to verify the accuracy of the information furnished. It may be released to appropriate Federal, State, and local agencies when relevant, to civil, criminal, or regulatory investigators, and to prosecutors. Failure to provide any information may result in a delay or rejection of your eligibility approval. The Department is authorized to ask for this information by the National Affordable Housing Act of 1990. Instructions: Each adult member of the household must sign a HOME Program Eligibility Release Form prior to the receipt of benefit and on an annual basis to establish continued eligibility. Additional signatures must be obtained from new adult members whenever they join the household or whenever members of the household become 18 years of age. NOTE: THIS GENERAL CONSENT MAY NOT BE USED TO REQUEST A COPY OF A TAX RETURN. IF A COPY OF A TAX RETURN IS NEEDED, IRS FORM 4506, REQUEST FOR COPY OF TAX FORM MUST BE PREPARED AND SIGNED SEPARATELY. Information Covered: Inquiries may be made about items initialed by applicant/tenant: Income (all sources) Assets (all sources) Other Other Other Verification Required Initials Authorization: I authorize the above-named organization and HUD to obtain information about me and my household that is pertinent to eligibility for participation in the HOME Program. I acknowledge that: (1) A photocopy of this form is as valid as the original. (2) I have the right to review the file and the information received using this form (with a person of my choosing to accompany me). (3) I have the right to copy information from this file and to request correction of information I believe inaccurate. (4) All adult household members will sign this form and cooperate with the owner in this process. Head of Household Signature, Printed Name, and Date: Family Member HEAD Other Adult Member of the Household Signature, Printed Name, and Date: Family Member #2 X Other Adult Member of the Household Signature, Printed Name, and Date: Family Member #3 X Other Adult Member of the Household Signature, Printed Name, and Date: Family Member #4 X X