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Discrimination Prohibited: The landlord will not discriminate based upon race,
color, religion, creed, national origin, sex, age, familial status, or disability.
OMB Control # 2502-0581
Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants
SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING
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.
Cell Phone No:
Name of Additional Contact Person or Organization:
Cell Phone No:
E-Mail Address (if applicable):
Relationship to Applicant:
Reason for Contact: (Check all that apply)
Assist with Recertification Process
nable to contact you
Change in lease terms
ermination of rental assistance
Change in house rules
viction from unit
Late payment of rent
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.
Check this box if you choose not to provide the contact information.
Signature of Applicant Date
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-