MHA Self-Certification Form
Unit Address:
Inspection Date:
This form must be signed by both the owner/agent and the tenant head of
household and returned within 28 days of the inspection. No other member
of the tenant’s household may sign on behalf of the head of household. Failure of the tenant to
cooperate with the timely return of this document will be grounds to initiate termination of
housing assistance.
Please return the signed and dated form, MHA list of failed items, and any required
documentation to one of the following:
Phone: 334-206-7185 MHA Inspections
525 S. Lawrence St.
Montgomery AL
If this certification is not fully completed and rec
eived by MHA within the required time frame,
the unit will be in Final Fail Status. Failed HQS status will result in cancellation and/or
abatement of the HAP Contract. No retroactive payments will be made for the time the rent
was abated.
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 statements or entry, in any matter
within the jurisdiction of any department or agency of the United States, shall be fined not more than
$10,000 or imprisoned for not more than five years, or both.
I certify that the MHA-required repairs are complete and the cited HQS deficiencies have been
corrected. I understand that any falsification of information is grounds for HAP contract
cancellation and tenant program termination. I also understand that any falsification of
information may be grounds for referral to the Department of Housing and Urban Development
(HUD) Office of Inspector General and/or local authorities for criminal prosecution.
_______________________________ _______________________________
Owner/Agent Printed Name Head of Household Printed Name
_______________________________ _______________________________
Owner/Agent Signature Head of Household Signature
_______________________________ _______________________________
Owner/Agent Telephone Number Head of Household Telephone Number
_______________________________ _______________________________
Date Signe by Owner/Agent Date Signed by Head of Household
I do not agree with this certification
and request an inspection by MHA
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