Certification Application (Rev 1/2020) Page 1 of 4

3460 S Sherman #101

Englewood CO 80113

(303) 761-6200 (P) (303) 781-5503 (F)

www.innovativehousingconcepts.org

CERTIFICATION APPLICATION

Initial Certification_____ Annual Recertification______

Instructions: Please print. Do not leave any blanks. Answer every question on the front and back of this

form. If an area of this form does not apply to you, please write the word “NONE.” Incomplete applications

will be returned and may delay your assistance. Please return this form and your verifications back to

Innovative Housing Concepts within 10 days of receipt. You MUST supply all supporting documentation

with this form.

Head of Household

Name __________________________________________ Age________________________________

Address ________________________________________Driver’s License or ID # ______________________

City/State______________________________________ Zip ________________________________

Home Phone __________________________________ Work phone _________________________

Message Phone _________________________________ Fax ________________________________

Email Address __________________________________ Car Make/Model/Yr. _____________________

Spouse or Other Adult

Name ________________________________________ Driver’s License or ID# _______________________

Work phone ___________________________________ Fax _____________________________________

Is any member of your household required to register in any state as a lifetime sex offender?

Yes ___ No ___

Have you been convicted of a crime in the last 7 years? Yes ___ No ___

Do you wish to renew your lease with your present landlord? Yes ___ No ____

Certification Application (Rev 1/2020) Page 2 of 4

List all member of your household including yourself.

Use a separate piece of paper if you need more lines.

First Name Last Name Sex Relationship Birth date Age

Self

If you are adding any new members of your family you must provide Birth Certificate (or Picture ID for

adult), Social Security number and if an adult, permission from your landlord.

Student Status

Are there any full time students over 18 years of age in your family? List name and provide school verification.

Name _________________________________________ School ___________________________________

Name _________________________________________ School ___________________________________

Child Care

Do you have day care expenses? Yes__ No____ Provide documentation

Name of child (children) in day care:

________________________________________________________________________________________

Name of child care provider ______________________________ Phone __________________________

Amount you pay per child; $ _________________ per _____________________

Child Support

Do you receive Child Support? Yes ___ No _____ Provide documentation of payments

Name of children __________________________________________________________

Name of payee ___________________________________________________________

Certification Application (Rev 1/2020) Page 3 of 4

Income

List ALL sources and types of income for all members of your household. (Employment, OAP, Social

Security, SSI, AND OAP, TANF, VA Pension, Unemployment, Worker’s Comp., Pension, Self-

Employment, Other).

NAME SOURCE OF INCOME AMOUNT PER

Any others? (i.e. Food Stamps, etc. ____________________________________________________________

NOTE: ALL SOURCES OF INCOME WILL BE VERIFIED BY THE HOUSING AUTHORITY.

Assets

Please list ALL bank accounts. (Savings, Checking, Stocks, Bonds, IRA’s; CD accounts and other) for all household

members.

NAME OF BANK ACCOUNT NO. INTEREST RATE CURRENT BALANCE

Do you own any real estate? Yes ____ No____ Value ______________________________________________

Have you disposed of any assets during the last two years? Yes___ No___ What was the value? _______________

Medical

If you are over 62 years of age or disabled, please supply documentation of all medical

expenses: Payments, bills, pharmacy printouts, and insurance payments.

Emergency Contact

In case of emergency notify: _ Relationship

Address __

Phone _ 2nd Phone

Certification Application (Rev 1/2020) Page 4 of 4

Certification

I/We (any family member over 18) certify that the information given to the Innovative Housing

Concepts on household composition, income, net family assets and allowances and deductions

is accurate and complete to the best of my/our knowledge. I/We understand that I/We are

required to report any changes in household composition, income, net family assets and

allowances, and deductions in writing within 10 days of their occurrence to the Innovative

Housing Concepts. I/We also understand that false statements or information are punishable

under federal law as well as grounds for termination of housing assistance of tenancy.

Date

Print Head of Household

Signature Head of Household

Date

Print Spouse/Other Adult

Signature Spouse/Other Adult

Date

Print Other Adult

Signature Other Adult

Several forms accompany this application. They must all be signed by all household

members over 18 years of age.

Thank you for your cooperation. Any delay in returning this paperwork could result in

termination of your Housing Assistance.

Original is retained by the requesting organization. form HUD-9886 (07/14)ref. Handbooks 7420.7, 7420.8, & 7465.1

Authorization for the Release of Information/Privacy Act Noticeto the U.S. Department of Housing and Urban Development (HUD) OMB CONTROL NUMBER: 2501-0014

and the Housing Agency/Authority (HA) exp. 07/31/2021

Persons who apply for or receive assistance under the followingprograms are required to sign this consent form:

PHA-owned rental public housingTurnkey III Homeownership OpportunitiesMutual Help Homeownership OpportunitySection 23 and 19(c) leased housingSection 23 Housing Assistance PaymentsHA-owned rental Indian housingSection 8 Rental CertificateSection 8 Rental VoucherSection 8 Moderate Rehabilitation

Failure to Sign Consent Form: Your failure to sign the consentform may result in the denial of eligibility or termination ofassisted housing benefits, or both. Denial of eligibility or termi-nation of benefits is subject to the HA’s grievance procedures andSection 8 informal hearing procedures.

Sources of Information To Be ObtainedState Wage Information Collection Agencies. (This consent islimited to wages and unemployment compensation I have re-ceived during period(s) within the last 5 years when I havereceived assisted housing benefits.)

U.S. Social Security Administration (HUD only) (This consent islimited to the wage and self employment information and pay-ments 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 islimited to unearned income [i.e., interest and dividends].)

Information may also be obtained directly from: (a) current andformer employers concerning salary and wages and (b) financialinstitutions concerning unearned income (i.e., interest and divi-dends). I understand that income information obtained from thesesources will be used to verify information that I provide indetermining eligibility for assisted housing programs and the levelof benefits. Therefore, this consent form only authorizes releasedirectly from employers and financial institutions of informationregarding any period(s) within the last 5 years when I havereceived assisted housing benefits.

Authority: Section 904 of the Stewart B. McKinney HomelessAssistance Amendments Act of 1988, as amended by Section 903of the Housing and Community Development Act of 1992 andSection 3003 of the Omnibus Budget Reconciliation Act of 1993.This law is found at 42 U.S.C. 3544.

This law requires that you sign a consent form authorizing: (1)HUD and the Housing Agency/Authority (HA) to request verifi-cation of salary and wages from current or previous employers; (2)HUD and the HA to request wage and unemployment compensa-tion claim information from the state agency responsible forkeeping that information; (3) HUD to request certain tax returninformation from the U.S. Social Security Administration and theU.S. Internal Revenue Service. The law also requires independentverification of income information. Therefore, HUD or the HAmay request information from financial institutions to verify youreligibility and level of benefits.

Purpose: In signing this consent form, you are authorizing HUDand the above-named HA to request income information from thesources listed on the form. HUD and the HA need this informationto verify your household’s income, in order to ensure that you areeligible for assisted housing benefits and that these benefits are setat the correct level. HUD and the HA may participate in computermatching programs with these sources in order to verify youreligibility and level of benefits.

Uses of Information to be Obtained: HUD is required to protectthe income information it obtains in accordance with the PrivacyAct of 1974, 5 U.S.C. 552a. HUD may disclose information(other than tax return information) for certain routine uses, such asto other government agencies for law enforcement purposes, toFederal agencies for employment suitability purposes and to HAsfor the purpose of determining housing assistance. The HA is alsorequired to protect the income information it obtains in accordancewith any applicable State privacy law. HUD and HA employeesmay be subject to penalties for unauthorized disclosures or im-proper uses of the income information that is obtained based on theconsent form. Private owners may not request or receiveinformation authorized by this form.

Who Must Sign the Consent Form: Each member of yourhousehold who is 18 years of age or older must sign the consentform. Additional signatures must be obtained from new adultmembers joining the household or whenever members of thehousehold become 18 years of age.

PHA requesting release of information; (Cross out space if none) IHA requesting release of information: (Cross out space if none)(Full address, name of contact person, and date) (Full address, name of contact person, and date)

U.S. Department of Housingand Urban DevelopmentOffice of Public and Indian Housing

X

Original is retained by the requesting organization. form HUD-9886 (07/14)ref. Handbooks 7420.7, 7420.8, & 7465.1

Signatures:

_____________________________________________ ______________Head of Household Date

___________________________________________Social Security Number (if any) of Head of Household

__________________________________________________ _______________Spouse Date

__________________________________________________ _______________Other Family Member over age 18 Date

__________________________________________________ _______________Other Family Member over age 18 Date

Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form forthe purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs thatreceive income information under this consent form cannot use it to deny, reduce or terminate assistance without firstindependently verifying what the amount was, whether I actually had access to the funds and when the funds were received. Inaddition, I must be given an opportunity to contest those determinations.

This consent form expires 15 months after signed.

__________________________________________________ ________________Other Family Member over age 18 Date

__________________________________________________ ________________Other Family Member over age 18 Date

__________________________________________________ ________________Other Family Member over age 18 Date

__________________________________________________ ________________Other Family Member over age 18 Date

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 ofinformation 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 9886. Any person who knowingly or willfullyrequests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not morethan $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, againstthe officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use.

Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this informationby the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the FairHousing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants andparticipants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income andother information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your familywill pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoringHUD-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 regulatoryinvestigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permittedor 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 memberssix years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provideany of the requested information may result in a delay or rejection of your eligibility approval.

Authorization for the Release of Information (Rev 7/2018) Page 1 of 2

Authorization for the Release of Information

Organization requesting release of information:

Englewood Housing Authority

dba Innovative Housing Authority

and Sheridan Housing Authority

3460 S. Sherman Street, Suite 101

Englewood, CO 80113

Phone (303) 761-6200 Fax (303) 781-5503

Purpose: Housing Authority may use this authorization and the information obtained with it, to administer

and enforce program rules and policies.

Authorization: I authorize the release of any information (including documentation and other materials)

pertaining to my eligibility for, participation in, and/or the enforcement of Housing Authority’s housing

program. I authorize the above named organization to obtain and share information about me or my family

that is pertinent to eligibility for, or participation in, assisted housing programs and to obtain information

on wages or unemployment compensation from State Employment Agencies.

Information Inquiries may be made about:

Child Care Expenses

Credit History

Criminal Activity

Family Composition

Employment, Income, Pensions, Assets

Federal, State, County, or Local Benefits

Handicapped Assistance Expenses

Identity and Marital Status

Medical Expenses

Social Security Numbers

Residences and Rental History

Release to speak with a specific individual

or agency.

Individual to be contacted:

Agency:

____________________________________________

Individuals or Organizations That May

Release Information:

Any individual or organization including any

governmental organization may be asked to

release information. Examples include:

Departments of Social Services

Banks and Other Financial Institutions

Courts, Credit Bureaus

Law Enforcement Agencies

Employers

Landlords

Providers of:

Alimony, Child Care,

Child Support, Credit,

Handicapped Assistance,

Medical Care, Pharmacies,

Pensions/Annuities

Schools and Colleges

Dept. of Labor and Employment

U.S. Social Security Administration

U.S. Postal Service

U.S. Department of Veterans Affairs

Utility Companies

Authorization for the Release of Information (Rev 7/2018) Page 2 of 2

Computer Matching Notice and Consent: I agree that the Englewood Housing Authority and or the

Department of Housing and Urban Development (HUD) may conduct computer matching programs with

other governmental agencies including Federal, State, Tribal or local agencies.

Conditions:

• I agree that photocopies of this authorization may be used for the purposes stated above.

• I understand that each member of the household who is 18 years of age or older must sign the

authorization.

• I understand that if I do not sign this authorization, my housing assistance may be denied or terminated.

• I understand that this authorization will expire 15 months from the date it is signed.

Signatures

Warning: Section 1001 of Title 18, United States Code makes it a criminal offense to make willful, false

statements of misrepresentation to any Department or Agency of the United States as to any matter within

its jurisdiction.

____________________________________________________________________________________ Head of Household (Print) Signature Date Last 4 of SS Number

_____________________________________________________________________________________ Co-Head/Spouse (Print) Signature Date Last 4 of SS Number

Other Adult Family Member Signature (Print) Signature Date Last 4 of SS Number

_____________________________________________________________________________________________

Other Adult Household Member (Print) Signature Date Last 4 of SS Number

__________________________________________________________________________________________

Live-In-Aide) (Print) Signature Date Last 4 of SS Number

Obligations of the Family (Rev 7/2018) Page 1 of 2

SECTION 8 PROGRAM PARTICIPANT

Obligations of the Family

A. When the family’s unit is provided and the HAP contract is executed, the family must

follow the rules listed below in order to continue participating in the housing choice

voucher program.

B. The family must:

• Supply any information that the HA or HUD determines to be necessary including

evidence of citizenship or eligible immigration status, and information for use in a

regularly scheduled reexamination or interim reexamination of family income and

composition. All changes must be reported within 10 days. Failure to report

changes could result in termination of housing assistance and charges for back

rent.

• Disclose and verify social security numbers and sign and submit consent forms

for obtaining information.

• Supply any information requested by the HA to verify that the family is living in

the unit or information related to family absence from the unit.

• Promptly notify the HA in writing when the family is away from the unit for an

extended period of time in accordance with HA policies.

• Allow the HA to inspect the unit at reasonable times and after reasonable notice.

• Notify the HA and the owner in writing before moving out of the unit or

terminating the lease.

• Use the assisted unit for residence by the family. The unit must be the family’s

only residence.

• Promptly notify the HA in writing of the birth, adoption or court-awarded custody

of a child.

• Request HA written approval to add any other family member as an occupant of

the unit.

• Promptly notify the HA in writing if any family member no longer lives in the

unit.

• Give the HA a copy of any owner eviction notice.

• Pay utility bills and provide and maintain any appliances that the owner is not

required to provide under the lease.

Obligations of the Family (Rev 7/2018) Page 2 of 2

• Comply with your lease. It is your responsibility to fulfill the obligations under

the lease. Remember to pay your portion of the rent on time, keep the noise level

down, keep the unit cleaned and do not damage the property.

• Pay only the rent specified by the Housing Authority.

C. Any information the family supplies must be true and complete.

D. The family (including each family member) must not:

• Own or have any interest in the unit (other than in a cooperative, or the owner of a

manufactured home leasing a manufactured home space).

• Commit any serious or repeated violation of the lease.

• Commit fraud, bribery or any other corrupt or criminal act in connection with the

program.

• Engage in drug-related criminal activity or violent criminal activity or other

criminal activity that threatens the health, safety or right to peaceful enjoyment of

other residents and persons residing in the immediate vicinity of the premises.

• Sublease or sublet the unit or assign the lease or transfer the unit.

• Receive housing choice voucher assistance while receiving another housing

subsidy, for the same unit or different unit under any other Federal, State, or local

housing assistance program.

• Damage the unit or premises (other than damage from ordinary wear and tear) or

permit any quest to damage the unit or premises.

• Receive housing choice voucher program housing assistance while residing in a

unit owned by a parent, child, grandparent, sister or brother or any member of the

family, unless the HA has determined (and had notified the owner and the family

of such determination) that approving rental of the unit, notwithstanding such

relationship, would provide reasonable accommodation for a family member who

is a person with disabilities.

• Engage in or threaten abusive or violent behavior toward any Housing Authority

personnel.

I have read and understand the above Obligations of the Family.

__________________________________________ ______________________

Signature of the Head of Household Date

__________________________________________ ______________________

Signature of Spouse or Other Adult Family Member Date

Declaration of Section 214 Status (Rev 7/2018) Page 1 of 2

DECLARATION OF SECTION 214 STATUS

I,____________________________________________ certify, under penalty of perjury, that to the best of my

knowledge, I am lawfully within the United States because:

( ) I am a citizen by birth, naturalized citizen or national of the United States.

OR:

( ) I have eligible immigration status and I am 62 years of age or older (attach proof of age)

OR:

( ) I have eligible immigration status as checked below (see reverse side of this form for explanations).

Attach INS document(s) evidencing eligible immigration status and signed verification consent form.

( ) Immigrant status under #1001(a)(15) or 10(a)(20) of the INA

OR:

( ) Permanent residence under #249 of INA

OR:

( ) Refugee, asylum or conditional entry status under #207, 208 or 203 of the INA

OR:

( ) Parole status under #212(d)(f) of the INA

OR:

( ) Threat to life of freedom under #243(h) of the INA

OR:

( ) Amnesty under #254 of the INA

___________________________________ ___________________________________

Signature of Family Member Date

( ) Check box if signature of adult residing in the unit is responsible for a child named on statement above.

HA: Enter INS/SAVE Primary Verification #________________________Date______________

Warning: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and willfully makes or

uses a document or writing containing any false, fictitious or fraudulent statement or entry, in any

manner within the jurisdiction of any department or agency of the United States, shall be fined not more

that 410,000 or imprisoned for not more than five years, or both.

Notice to applicants and tenants: In order to be eligible to receive the housing assistance

sought, each applicant for or recipient of housing assistance must be lawfully within the

United States. Please read the Declaration statement carefully and sign and return to the

Housing Authority’s Admissions Office. Please feel free to consult with an immigration

lawyer or other immigration expert of your choosing.

Declaration of Section 214 Status (Rev 7/2018) Page 2 of 2

The following footnotes pertain to noncitizens that declare eligible immigration status in one of the following

categories:

Eligible immigration status and 62 years of age or older: For noncitizens who are 62 years of age or older or

who will be 62 years of age or older and receiving assistance under a Section 214 covered program on June 19,

1995. If you are eligible and elect to select this category, you must include a document providing evidence of

proof of age. No further documentation of eligible immigration status is required.

Immigrant status under 101(a)(15) or 101(a)(20) of INA: A noncitizen lawfully admitted for permanent

residence, as defined by 101(a)(20) of the Immigration and Nationality Act (INA), as an immigrant, as defined

by 101(a)(15) of the INA (8 U.S.C. 1101(a)(20) and 1101(a)(15), respectively {immigration status]. This

category includes a noncitizen admitted under 210 or 210A of the INA (8 U.S.C. 1160 or 1161), [special

agricultural worker status] who has been granted lawful temporary resident status.

Permanent residence under 249 of INA: A noncitizen who entered the U.S. before January 1, 1972, or such

later date as enacted by law, and has continuously maintained residence in the U.S. since then, and who is not

ineligible for citizenship, but who is deemed to be lawfully admitted for permanent residence as a result of an

exercise of discretion by the Attorney General under 249 of the INA (8 U.S.C. 1259) [amnesty granted under

INA 249].

Refugee, Asylum or conditional entry status under 207, 208, or 203 of the INA: A noncitizen who is

lawfully present in the U.S. pursuant to an admission under 207 of the INA (8 U.S.C. 1157) [refugee status];

pursuant to the granting of asylum (which has not been terminated under 208 of the INA (8 U.S.C. 1158)

{asylum status]; or as a result of being granted conditional entry under 203(a)(7) of the INA (U.S.C. 1153(a)(7)

before April 1, 1980, because of persecution or fear of persecution on account of race, religion or political o

pinion or because of being uprooted by catastrophic national calamity {conditional entry status].

Parole status under 212(d)(5) of INA: A noncitizen who is lawfully present in the U.S. as a result of the

Attorney General’s withholding deportation under 243(h) of the INA (8 U.S.C. 1253(h)) [threat to life or

freedom].

Amnesty under 245(a) of the INA: A noncitizen lawfully admitted for temporary or permanent residence

under 245(a) of the INA (8 U.S.C. 1255(a)) [amnesty granted under INA 245(a)].

Instructions to Housing Authority: Following verification of status claimed by persons declaring eligible

immigration status (other than for noncitizens age 62 or older and receiving assistance on June 19, 1995), the

HA must enter INS/SAVE Verification Number and date that it was obtained. An HA signature is not required.

Instructions to Family Member for Completing Forms: On opposite page, print or type first name, middle

initial(s) and last name. Place an “x” in the appropriate boxes. Sign and date at bottom of page. Place an “x” in

the box below the signature if the signature is by the adult residing in the unit who is responsible for the child.

OMB Control # 2502-0581 Exp. (02/28/2019)

Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants

SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING This form is to be provided to each applicant for federally assisted housing

Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form.

Applicant Name:

Mailing Address: Telephone No: Cell Phone No:

Name of Additional Contact Person or Organization: Address: Telephone No: Cell Phone No: E-Mail Address (if applicable): Relationship to Applicant: Reason for Contact: (Check all that apply)

Emergency Unable to contact you Termination of rental assistance Eviction from unit Late payment of rent

Assist with Recertification Process Change in lease terms Change in house rules Other: ______________________________

Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you.

Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law.

Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992) requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of 1975.

Check this box if you choose not to provide the contact information.

Signature of Applicant Date

The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information. Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the collection displays a currently valid OMB control number. Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions.

Form HUD- 92006 (05/09)

 

 

                                                                                                            ENGLEWOOD HOUSING AUTHORITY