1b. Ethnicity: Hispanic or Latino Not Hispanic or Latino
IV. HOUSEHOLD INCOME AND COMPOSITION
Total number of people in household: _______________
Number of Adults F:_____________ M:_____________
Number of Children F:_____________ M:_____________
Total household annual income earned from farm labor: $_____________________
Total household annual income from all sources: $__________________________
V. CERTIFICATION
I do hereby swear and attest that all of the listed information is true, complete, and correct. Additionally, I certify that if I
accept housing assistance from the USDA-RHS, that the assisted unit will be the primary residence of my household. I
understand that false information or statements or omission of information are punishable under federal law, and are
grounds for denial of admission into the program, or termination from the program.
WARNING – TITLE 18 SECTION 1001 OF THE UNITED STATES CODE STATES THAT ANY PERSON WOULD BE
GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS
TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES.
Print Qualifying Household Member Name Signature of Qualifying Household Member Date
VI. AUTHORIZATION TO VERIFY INFORMATION
The Housing Authority is required to verify all information regarding your family composition, citizenship and residency
status, income, assets, and any information deemed necessary to process your application. Therefore, your name cannot
be placed on the waiting list for USDA-RHS Farm Worker Housing unless you consent to the following statement.
I hereby give my consent to have the Housing Authority of the County of Santa Cruz and the United States
Department of Agriculture Rural Housing Service, obtain any and all information deemed necessary to
determine my/our eligibility for housing assistance. Therefore, I authorize the release of any of the information
described below, as requested by the Housing Authority of the County of Santa Cruz or by the United States
Department of Agriculture Rural Housing Service. I understand that this release of information includes the
collection of information regarding my citizenship and residency status, employment, benefits, child support
and spousal support, bank accounts, or any other income or asset information. I understand that this
information will be kept confidential and is being requested for the purpose of determining my/our eligibility
for housing assistance. I also authorize this form to be photocopied and used as an original.
Print Qualifying Household Member Name Signature of Qualifying Household Member Date
This institution is an equal opportunity provider and employer.
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint
Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html
, or at any USDA office, or call (866) 632-9992 to
request the form. You may also write a letter containing all of the information requested in the form. Send your completed
complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence
Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at
program.intake@usda.gov.”
