PREFERENCES:  Please indicate if you qualify for any of the preferences indicated below by checking the box next to the appropriate preference.  

RENTAL HISTORY:  

PETS & ASSISTANCE/COMPANION ANIMALS:   Please review the property pet/assistance animal rules.  The presence of any animal must be approved before housing the animal in the unit.   

UNIT SIZE/FEATURES: The owner/agent will take your unit preferences/requirements in to consideration.  The owner/agent’s occupancy standards indicate a minimum of one person per bedroom and maximum of two people per bedroom.  Please indicate unit size preferences below.  Please indicate any necessary special features below.   

INCOME AND ASSET INFORMATION: In order to determine eligibility and to ensure that your family receives the correct assistance, please provide the following information. 

If yes, please provide the name and address of your present employer below. 

Assets 

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, HUD, the PHA and any owner (or any employee of HUD, the PHA 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 this verification form is restricted to the purposes cited above.  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 PHA or the owner responsible for the unauthorized disclosure or improper use.  Penalty provisions for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7) and (8).  Violation of these provisions are cited as violations of 42 U.S.C.  408 (a) (6), (7) and (8). 

APPLICANT CERTIFICATION 

By signing this document, I certify that if selected to receive assistance, the unit I/we occupy will by my/our only residence.  I/we understand that the above information is being collected to determine my/our eligibility.  I/we authorize the 

owner/manager/PHA to verify all information provided on this application and to contact previous or current landlords or other sources of credit and verification information which may be released to appropriate Federal, State, or local agencies. I/we certify that the statements made in the application are true and complete.  I/we understand that providing false statements or information is punishable under Federal Law.