This form is to be completed by individuals wishing to be served (applicants) and those that are currently served (tenants) in housing assisted by the Department of Housing and Urban Development.
Owner and agents are required to offer the applicant/tenant the option to complete the form. The form is to be completed at initial application or at lease signing. In-place tenants must also be offered the opportunity to complete the form as part of the next interim or annual recertification. Once the form is completed it need not be completed again unless the head of household or household composition changes. There is no penalty for persons who do not complete the form. However, the owner or agent may place a note in the tenant file stating the applicant/tenant refused to complete the form. Parents or guardians are to complete the form for children under the age of 18.
The Office of Housing has been given permission to use this form for gathering race and ethnic data in assisted housing programs. Completed documents for the entire household should be stapled together and placed in the household's file.
If you have any questions, please call the office.
Please be advised that HUD requires us to inform you of the following: Penalties for false information include eviction, loss of assistance, fines up to $10,000 and imprisonment up to five years. For a sample of cases, HUD will compare the information families’ supply with information Federal, State, or Local agencies have on family’s income and household composition.
The information on this form is being collected by the Department of Housing and Urban Development (HUD) to determine the applicant’s eligibility; the recommended unit size; and the amount the tenant(s) must pay toward rent.