Page 1 of 2
Step 2
Public Housing Applicant:
Now that you submitted your online application, there are certain verification documents, legal documents and proof
of income statements to be submitted to the BHA Main Office. This letter is to serve as a guide for what those
verifications are. Please note this helpful guide may not include all the verifications needed by the BHA for your
family. The BHA will notify you by mail or email if other documents are needed. Please submit all verifications and
documents within 10 days of online application submittal.
Applicant / Head of Household Name:
Confirmation Number for Online Application
Did you receive a confirmation number for your online application? If so, write it down here:
Sign the Attached Documents
Attached to this letter are the following documents that must be signed by the Head of Household AND all other
adult members of the household:
HUD Form 92006 “Supplement to Application for Federally Assisted Housing”
“Authorization for Release of Information”
HUD Form 9886 “Authorization for Release of Information/Privacy Act Notice
HUD Form 52675 “Debts Owed to PHAs and Terminations”
“Consent for Criminal Background Check”
Housing Suitability Screening
Verifications for Adults
Original Social Security Card of each member of the household (Copies can be mailed, however an original
MUST be shown to BHA Intake before a unit is offered.)
Birth Certificate
Driver’s License, Military ID, Employment Card or Passport
Verifications for Children
Original Social Security Card (Copies can be mailed, however an original MUST be shown to BHA Intake before
a unit is offered.)
Birth Certificate
Adoption papers (if applicable)
Custody agreement (if applicable)
Health and Human Services ID (if applicable)
Certified school records (if applicable)
Preference Point Verifications
c Did you select any preference points on the application? If so, submit the proper documentation to prove you
qualify for those preference points.
Bloomington Housing Authority
1007 N Summitt Street
Bloomington, IN 47404
Phone: 812-339-3491
Fax: 812-339-7177
Page 2 of 2
Sources of Income Verification
Please turn in recent documentation for all sources of income, including, but not limited to:
c Employment-60 days of pay stubs no more than 30 days old c Unemployment c TANF Award Letter
c Disability Income from a Job c Worker’s Compensation c Military Pay c Odd/Seasonal Jobs
c Military Pension c Retirement Pension c SNAP/ Food Stamps Award Letter
c Child Support-Divorce Decree or Print Out (dating back at least 1 year)
c Social Security-ANY form-including: SS, SSDI, SSI, SS Widows, SS survivors, ANY back-pay
c Prior year’s tax records (Only if self-employed, including tax forms filed, W-2’s, etc.)
c Student Aid-ANY form, including but not limited to: Grants, Loans, Scholarships, Fellowships, Work Study,
Internships, and Apprenticeships
c Self-Employment: we will need a signed and dated statement of self-certification
c Trustee Assistance: we will need a statement on the trustee’s letterhead
c Energy Assistance: we will need the SCCAP worksheet, or a statement on SCCAP letterhead
c Assistance from churches/other agencies: we will need a statement on letterhead
c Lottery/Gambling winnings- any form of Hoosier Lottery, any other State Lottery, Pull-tabs, Scratch Offs, Bingo
c Selling/Reselling/Salvaging Items including but not limited to: Plasma, Aluminum/Steel Cans, Scrap Metals,
Yard/Garage sales, Card Collections (Baseball, Basketball, Football, etc.), any type of Collection selling
For the following income types we will need a signed and dated statement that includes the phone number from the
person(s) giving the money:
c Work for Cash c Baby Sitting c Money from family/friends
ANY other income that is not listed above MUST be reported on the application and documents supporting the
income must be brought in for verification.
Assets (must be a current statement dated within last 60 days)
c Checking accounts c Savings accounts c Bonds c IRAs c Money Market accounts c UTMA accounts
c House c CDs c Stocks c Mobile Home c Trailer c Land c Investments c Inheritance
c ANY other assets
Children & Child Care
c Proof of Custody/Guardianship (including court documentation or school records showing the child is registered
in school under the applicants address) c Signed statement from childcare provider
c If you are expecting a child we will need proof of pregnancy or a signed doctor’s statement.
If you are handicapped/disabled or elderly (62 or over)
c Medical insurance statement-must show how often premium is paid
c Signed statements from doctors for your ongoing out-of-pocket expenses
c Signed statements or print out from pharmacies for your out-of-pocket expenses
I understand if I fail to provide the required documentation or make false statements or misinterpretations on
my application, my application for the Public Housing program will be considered incomplete and therefore
will not be accepted without further notice.
HOH Signed: ___________________________________________ Date: ____________________
OMB Control # 2502-0581
Exp. (11/30/2015)
Optional and Supplemental Contact Information for HUD-Assisted Housing Applicants
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.
Check this box if you choose not to provide the contact information.
Applicant Name:
Mailing Address:
Telephone No: Cell Phone No:
Name of Additional Contact Person or Organization:
Telephone No: Cell Phone No:
E-Mail Address (if applicable):
Relationship to Applicant:
Reason for Contact: (Check all that apply)
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.
e of Applicant
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)
I authorize and direct any
state, or local agency,
business, or
to release
Authority of the City of
or materials needed to complete
verify my
assistance and/or to maintain my
continued occupancy
by or through the
Authority. I
and agree that this
obtained with its use may be given to and used by the
Authority in
administering and
program rules and
policies and
previous or
me or my
may be requested, this includes but is not limited
Identity and Marital Status
and Rental
Medical or Child Care
Credit and Criminal
that this
cannot be used to obtain any
about me that is not
to my
continued participation
in a housing
assistance program.
The groups or
that may be asked to release the above
information (depending
include but are not limited
Previous Landlords
Public Housing Agencies
Enforcement Agencies
and Alimony
Medical and Child Care
Schools and
Credit Bureaus and
Financial Institutions
and agree that the
Authority may conduct
computer matching
programs to verify
supplied for my
If a
match is done, I
understand that
have a right to
automated information
with other
state, or local
but not limited to State
Security agencies;
of Defense; Office
U. S. Postal Service; Social Security Agency and State Welfare and food
agree that a
of this
may be used for the purposes listed above.
will stay in effect for as long as I remain an
in any
by the
Housing Authority.
refusal to sign this or any required consent form may result in the denial of assistance or
of assisted
housing benefits.
Adult Member:
Original is retained by the requesting organization.
form HUD-9886
ref. Handbooks 7420.7, 7420.8, & 7465.1
Authorization for the Release of Information/
Privacy Act Notice
to the U.S. Department of Housing and Urban Development (HUD) OMB CONTROL NUMBER: 2501-0014
and the Housing Agency/Authority (HA) exp. 1/31/2014
Persons who apply for or receive assistance under the following
programs are required to sign this consent form:
PHA-owned rental public housing
Turnkey III Homeownership Opportunities
Mutual Help Homeownership Opportunity
Section 23 and 19(c) leased housing
Section 23 Housing Assistance Payments
HA-owned rental Indian housing
Section 8 Rental Certificate
Section 8 Rental Voucher
Section 8 Moderate Rehabilitation
Failure to Sign Consent Form: Your failure to sign the consent
form may result in the denial of eligibility or termination of
assisted housing benefits, or both. Denial of eligibility or termi-
nation of benefits is subject to the HA’s grievance procedures and
Section 8 informal hearing procedures.
Sources of Information To Be Obtained
State Wage Information Collection Agencies. (This consent is
limited to wages and unemployment compensation I have re-
ceived during period(s) within the last 5 years when I have
received assisted housing benefits.)
U.S. Social Security Administration (HUD only) (This consent is
limited 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 is
limited to unearned income [i.e., interest and dividends].)
Information may also be obtained directly from: (a) current and
former employers concerning salary and wages and (b) financial
institutions concerning unearned income (i.e., interest and divi-
dends). I understand that income information obtained from these
sources will be used to verify information that I provide in
determining eligibility for assisted housing programs and the level
of benefits. Therefore, this consent form only authorizes release
directly from employers and financial institutions of information
regarding any period(s) within the last 5 years when I have
received assisted housing benefits.
Authority: Section 904 of the Stewart B. McKinney Homeless
Assistance Amendments Act of 1988, as amended by Section 903
of the Housing and Community Development Act of 1992 and
Section 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 for
keeping that information; (3) HUD to request certain tax return
information from the U.S. Social Security Administration and the
U.S. Internal Revenue Service. The law also requires independent
verification of income information. Therefore, HUD or the HA
may request information from financial institutions to verify your
eligibility and level of benefits.
Purpose: In signing this consent form, you are authorizing HUD
and the above-named HA to request income information from the
sources listed on the form. HUD and the HA need this information
to verify your household’s income, in order to ensure that you are
eligible for assisted housing benefits and that these benefits are set
at the correct level. HUD and the HA may participate in computer
matching programs with these sources in order to verify your
eligibility and level of benefits.
Uses of Information to be Obtained: HUD is required to protect
the income information it obtains in accordance with the Privacy
Act of 1974, 5 U.S.C. 552a. HUD may disclose information
(other than tax return information) for certain routine uses, such as
to other government agencies for law enforcement purposes, to
Federal agencies for employment suitability purposes and to HAs
for the purpose of determining housing assistance. The HA is also
required to protect the income information it obtains in accordance
with any applicable State privacy law. HUD and HA employees
may be subject to penalties for unauthorized disclosures or im-
proper uses of the income information that is obtained based on the
consent form. Private owners may not request or receive
information authorized by this form.
Who Must Sign the Consent Form: Each member of your
household who is 18 years of age or older must sign the consent
form. Additional signatures must be obtained from new adult
members joining the household or whenever members of the
household 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 Housing
and Urban Development
Office of Public and Indian Housing
Original is retained by the requesting organization.
form HUD-9886
ref. Handbooks 7420.7, 7420.8, & 7465.1
_____________________________________________ ______________
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 for
the purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs that
receive income information under this consent form cannot use it to deny, reduce or terminate assistance without first
independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In
addition, 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 of
information 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 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 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 information
by 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 Fair
Housing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and
participants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and
other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family
will pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoring
HUD-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 regulatory
investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted
or 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 members
six years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provide
any of the requested information may result in a delay or rejection of your eligibility approval.
Paperwork Reduction Notice: Public reporting burden for this collection of information is estimated to average 7 minutes
per response. This includes the time for respondents to read the document and certify, and any recordkeeping burden. This
information will be used in the processing of a tenancy. Response to this request for information is required to receive
benefits. The agency may not collect this information, and you are not required to complete this form, unless it displays
a currently valid OMB control number. The OMB Number is 2577‐0266, and expires 10/31/2019.
Public Housing (24 CFR 960)
Section 8 Housing Choice Voucher, including the Disaster Housing Assistance Program (24 CFR 982)
Section 8 Moderate Rehabilitation (24 CFR 882)
Project-Based Voucher (24 CFR 983)
The U.S. Department of Housing and Urban Development maintains a national repository of debts owed to Public
Housing Agencies (PHAs) or Section 8 landlords and adverse information of former participants who have voluntarily or
involuntarily terminated participation in one of the above-listed HUD rental assistance programs. This information is
maintained within HUD’s Enterprise Income Verification (EIV) system, which is used by Public Housing Agencies (PHAs)
and their management agents to verify employment and income information of program participants, as well as, to
reduce administrative and rental assistance payment errors. The EIV system is designed to assist PHAs and HUD in
ensuring that families are eligible to participate in HUD rental assistance programs and determining the correct
amount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUD
regulations at 24 CFR 5.233.
HUD requires PHAs, which administers the above-listed rental housing programs, to report certain information at the
conclusion of your participation in a HUD rental assistance program. This notice provides you with information on what
information the PHA is required to provide HUD, who will have access to this information, how this information is used
and your rights. PHAs are required to provide this notice to all applicants and program participants and you are
required to acknowledge receipt of this notice by signing page 2. Each adult household member must sign this form.
What information about you and your tenancy does HUD collect from the PHA?
The following information is collected about each member of your household (family composition): full name, date of
birth, and Social Security Number.
The following adverse information is collected once your participation in the housing program has ended, whether you
voluntarily or involuntarily move out of an assisted unit:
1. Amount of any balance you owe the PHA or Section 8 landlord (up to $500,000) and explanation for balance owed
(i.e. unpaid rent, retroactive rent (due to unreported income and/ or change in family composition) or other charges
such as damages, utility charges, etc.); and
2. Whether or not you have entered into a repayment agreement for the amount that you owe the PHA; and
3. Whether or not you have defaulted on a repayment agreement; and
4. Whether or not the PHA has obtained a judgment against you; and
5. Whether or not you have filed for bankruptcy; and
6. The negative reason(s) for your end of participation or any negative status (i.e.
, abandoned unit, fraud, lease
violations, criminal activity, etc.) as of the end of participation date.
U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
OMB No. 2577-0266 Expires 10/31/2019
Form HUD-52675
Who will have access to the information collected?
This information will be available to HUD employees, PHA employees, and contractors of HUD and PHAs.
How will this information be used?
PHAs will have access to this information during the time of application for rental assistance and reexamination of
family income and composition for existing participants. PHAs will be able to access this information to determine a
family’s suitability for initial or continued rental assistance, and avoid providing limited Federal housing assistance to
families who have previously been unable to comply with HUD program requirements. If the reported information is
accurate, a PHA may terminate your current rental assistance and deny your future request for HUD rental assistance,
subject to PHA policy.
How long is the debt owed and termination information maintained in EIV?
Debt owed and termination information will be maintained in EIV for a period of up to ten (10) years from the end of
participation date
or such other period consistent with State Law.
What are my rights?
In accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to its
implementation of the Federal Privacy Act of 1974 (24 CFR Part 16), you have the following rights:
1. To have access to your records maintained by HUD
, subject to 24 CFR Part 16.
2. To have an administrative review of HUD’s initial denial of your request to have access to your records maintained
by HUD.
3. To have incorrect information in your record corrected upon written request.
4. To file an appeal request of an initial adverse determination on correction or amendment of record request within
30 calendar days after the issuance of the written denial.
5. To have your record disclosed to a third party upon receipt of your written and signed request.
What do I do if I dispute the debt or termination information reported about me?
If you disagree with the reported information, you should contact in writing the PHA who has reported this information
about you. The PHA’s name, address, and telephone numbers are listed on the Debts Owed and Termination Report.
You have a right to request and obtain a copy of this report from the PHA. Inform the PHA why you dispute the
information and provide any documentation that supports your dispute. HUD's record retention policies at 24 CFR Part 908
and 24 CFR Part 982 provide that the PHA may destroy your records three years from the date your participation in the
program ends. To ensure the availability of your records, disputes of the original debt or termination information must be
made within three years from the end of participation date; otherwise the debt and termination information will be
presumed correct. Only the PHA who reported the adverse information about you can delete or correct your record.
Your filing of bankruptcy will not result in the removal of debt owed or termination information from HUD’s EIV system.
However, if you have included this debt in your bankruptcy filing and/or this debt has been discharged by the
bankruptcy court, your record will be updated to include the bankruptcy indicator, when you provide the PHA with
documentation of your bankruptcy status.
The PHA will notify you in writing of its action regarding your dispute within 30 days of receiving your written dispute.
If the PHA determines that the disputed information is incorrect, the PHA will update or delete the record. If the PHA
determines that the disputed information is correct, the PHA will provide an explanation as to why the information is
This Notice was provided by the below-listed PHA:
I hereby acknowledge that the PHA provided me with the
Debts Owed to PHAs & Termination Notice:
Signature Date
Printed Name
OMB No. 2577-0266 Expires 10/31/2019
Form HUD-52675
Consent for Criminal Background Check
MUST Be Completed By ALL Household Members Age 18 or Older
HUD regulations require all PHAs to obtain criminal background and sex offender registration information about all adult
household members applying for housing assistance. To enable the Bloomington Housing Authority (BHA) to do this, all
household members age 18 or older MUST answer the questions below and sign to consent to a background check.
The BHA will deny the application that does not provide complete and accurate information or does not consent to a
background check. Please answer ALL the following questions:
1) Have you been terminated from a federally assisted site within the past five years? Yes No
2) Do you currently use illegal drugs or abuse alcohol? Yes No
3) Are you currently subject under a state sex offender registration program? Yes No
4) Have you ever been convicted of a drug-related crime? Yes No
5) Have you been convicted of a crime within the past 5 years? Yes No
6) Are you currently charged with any of the above criminal activities? Yes No
7) Have you been released from jail within the past five (5) years? Yes No
If yes please list the reason(s) _______________________________________________________________________
8) Are you or any household member now charged with an unresolved crime which has not yet resulted in a plea of guilty,
a court trial, or the dropping of charges? Yes No
9) Please list all states in which you have lived or have held licenses to drive
10) Have you ever used or been known by any other name? Yes No
If yes, please list all names used:
I understand the above information is required to determine eligibility for assistance. I certify my answers are true and
complete to the best of my knowledge. I understand making false statements is grounds for denial or termination. I
authorize the BHA to verify the above information and consent to the release of the necessary information to determine
my eligibility. I authorize the release of criminal records and/or sex offender registration information to the BHA
or agencies contracted by the BHA to conduct criminal background checks.
Today’s Date
Applicant’s (or Other Adult Member’s) Full Name (Please Print)
Social Security Number Date of Birth
Applicant’s (or Other Adult Member’s) Signature
Housing Suitability Screening
Previous housing references:
List the address and landlord information (if applicable) for the last five (5) years. Attach additional sheet if necessary.
We cannot process the application without this information.
(Include Street, City, State)
Live With
Landlord, Home
Owner Name,
even if you were
not on a lease
Landlord, Home
Owner Telephone
Have you or any other household member ever been evicted? Yes No
If Yes: By Whom?__________________________ When?_________________ Why?_____________
For ALL adult members age 18 and over, please read, sign, and date the following: I give my permission for the
Bloomington Housing Authority to conduct a tenancy history check for the past five (5) years. I understand my previous
Landlords will be
______________________________________________ ___________________________________________
Signature Date Signature Date
_______________________________________________________________ ___________________________________________________________
Signature Date Signature Date
Zip Code
For All adult members over 18 years of age, please list their name, address, City, State, then the Zip Code that they have
lived in for the last five (5) years. Attach additional sheet if necessary.
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, sign and return it to the Housing Authority office. Please feel free to consult with
an immigration lawyer or other immigration expert of your choice.
I, ____________________________________, certify under penalty of perjury¹ that to
the best of my knowledge, I am lawfully within the United States because (please
check appropriate box):
( ) I am a citizen by birth, a naturalized citizen, or a national of the
United States; or
( ) I have eligible immigration status and I am 62 years of age or older.
(Attach proof of age)²; or
( ) I have eligible immigration status as checked below (see reverse 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 101(a)(20) of
the INA³; 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 or freedom under ¶243(h) of the INA ; or
[ ] Amnesty under ¶245A of the INA .
Signature Date
**PARENT/GUARDIAN must sign for family members under age 18. DO
NOT sign child’s name.
PHA: Enter INS/SAVE Primary Verification #:____________________Date:_____________
(See reverse side for footnotes and instructions)
1. 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 of agency of the United States, shall be fined not more than $10,000 or
imprisoned for not more than five years or both.
The following footnotes pertain to non-citizens who declare eligible immigration
status in one of the following categories:
2. Eligible immigration status and 62 years of age or older. For non-citizens who are 62
years of age and 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.
3. Immigrant status under¶101(a)(15) or 101 (a)(20) of INA. A non-citizen 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
(8U.S.C. 1101 (a)(20) and 1101 (a)(15), respectively [immigrant status].This category
includes a non-citizen 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.
4. Permanent residence under ¶249 of INA. A non-citizen 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 the, 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 INA (8 U.S.C. 1259)
[amnesty granted under INA 249].
5. Refugee, asylum or conditional entry status under ¶¶207. 208 or 203 of INA. A non-
citizen who is lawfully present in the U.S. pursuant to an admission under ¶207 of
INA (8 U.S.C. 1157) [refugee status]; pursuant to the granting of asylum (which has
not been terminated under ¶208 of INA (8 U.S.C. 1158) [asylum status]; or as a result
of being granted conditional entry under ¶203 (a)(7) of 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 opinion or because of being uprooted by catastrophic national
calamity [conditional entry status].
6. Parole status under ¶212 (d)(5) of INA. A non-citizen who is lawfully present in the
U.S. as a result of an exercise of discretion by the Attorney General for emergent
reasons or reasons deemed strictly in the public interest under ¶212(d)(5) of INA (8
U.S.C. 1182 (d)(5)) [parole status].
7. Threat to life or freedom under ¶243 (h) of INA. A non-citizen who is lawfully
present in the U.S. as a result of the Attorney General’s withholding deportation
under ¶243 (h) of INA (8 U.S.C. 1253 (h)) [threat to life or freedom].
8. Amnesty under ¶245A of INA. A non-citizen lawfully admitted for temporary or
permanent residence under ¶245A of INA (8 U.S.C. 1255a) [amnesty granted under
INA 245A].
Instructions to Housing Authority: Following verification of status claimed by persons declaring
eligible immigration status (other than for non-citizens age 62 or older and receiving assistance on
June 19, 1995), the PHA must enter INS/SAVE verification number and date that it was obtained. A
PHA signature is not required.
Instructions to Family Member for Completing Form: On opposite page, print or type first name,
middle initial(s) and last name. Place X or √ in the appropriate boxes. Sign and date at the bottom of
the page.