Fillable GEORGIA RENTAL ASSISTANCE RECERTIFICATION: HOUSEHOLD MEMBERS (City of Oakland)

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GEORGIA RENTAL ASSISTANCE RECERTIFICATION: HOUSEHOLD MEMBERS (City of Oakland)

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The GEORGIA RENTAL ASSISTANCE RECERTIFICATION: HOUSEHOLD MEMBERS (City of Oakland) form is 2 pages long and contains:

  • 2 signatures
  • 3 check-boxes
  • 33 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Oakland

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GEORGIA RENTAL ASSISTANCE
RECERTIFICATION: HOUSEHOLD MEMBERS
Page 1 of 2
Please choose one of the following, to describe the current number of household
members since the time you originally applied for rental assistance: (Use additional space
as needed)
No change: household members are the same.
Decrease: list names, age, gender of any person who is no longer living at the household
since initial application.
Name
Relation
DOB
SSN #
Gender
Name
Relation
DOB
SSN #
Gender
Name
Relation
DOB
SSN #
Gender
I
ncrease: list names, age, gender of any person who is now living at the household, but
was not living there at the time of initial application to the rental assistance program
Name
Relation
DOB
SSN #
Gender
Name
Relation
DOB
SSN #
Gender
GEORGIA RENTAL ASSISTANCE
RECERTIFICATION: HOUSEHOLD MEMBERS
Page 2 of 2
Name
Relation
DOB
SSN #
Gender
In signing this certification (including electronic signature) you are acknowledging
that falsification of documents or any material falsehoods or omissions in the Application,
including knowingly seeking duplicative benefits, is subject to state and federal criminal
penalties. You are particularly put on notice that 18 U.S.C. §1001 provides, among other
things, that whoever knowingly and willingly makes or uses a document or writing
containing any false, fictitious, or fraudulent statement or entry, in any matter within the
jurisdiction of any department or agency of the United States will be fined not more than
$10,000 or imprisoned for not more than five years, or both. Moreover, you understand and
accept that you are still bound by all certifications made in the attestation form from the
initial application.
___________________________________ ____________________
Applicant Signature Date
____________________________________ ____________________
Signature of Person Helping Complete Form Date
________________________________________
Printed Name of Person Helping Complete Form
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GEORGIA RENTAL ASSISTANCE RECERTIFICATION: HOUSEHOLD MEMBERS (City of Oakland)

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Completed 8 January 2022

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