Fillable Please read this carefully before completing the application (New Hampshire Housing)

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Please read this carefully before completing the application
• New Hampshire Housing operates the Housing Choice Voucher program. If you do not understand a
question, please call the Assisted Housing Division at New Hampshire Housing.
Please do not come to the office without an appointment.
• If you or anyone in your family is a person with disabilities and you need a reasonable accommodation
to complete this application, please refer to the “Notice of Right to Reasonable Accommodation” on
page 2.
• New Hampshire Housing will provide free interpretation services to clients who have Limited English
Proficiency. Para asistencia en español por favor contacte ésta oficina al 1-800-439-7247, extensión
9210. Los servicios de un intérprete se le proveerán sin costo alguno.
• If you do not receive an application confirmation letter from us within 30 days, please call 1-800-439-7247.
• If you move and do not update your address, your file will be inactivated during our yearly update.
You will need to re-apply if you cannot be contacted at the address you list on the application.
• Please answer all questions on the application form. Do not leave any questions blank. If a question
does not apply to you, please write “none”. All Yes or No questions must be checked (√). Be sure to refer
to the page of preferences and special programs because they can affect the length of wait time.
• Unless specifically indicated, all questions in this application apply to all members of the household.
• By your signature on the application you swear that all the information is true and complete. You
understand that any misrepresentation or failure to disclose information may result in denial or termination
of assistance.
• The legal head of household and spouse/co-head must sign and date the application.
To qualify for housing assistance an applicant must:
• Meet the HUD requirements for citizenship or immigrations status.
• Pay any money owed to New Hampshire Housing or any other housing authority.
• Not be subject to lifetime state sex offender registration requirements.
Return completed application to: New Hampshire Housing Finance Authority, PO Box 5087, Manchester, NH 03108
Language Assistance Services
ATTENTION: If you speak a language other than English, language assistance services, free of charge, are
available to you. Call 1-800-439-7247.
Español (Spanish) ATENCIÓN: Si usted habla español, servicios de asistencia lingüística, de forma gratuita,
están
a su disposición. Llame al 1-800-439-7247.
Português (Portuguese) ATENÇÃO: Se você fala português, encontram-se disponíveis serviços linguísticos
gratuitos. Ligue para
1-800-439-7247.
Kreyòl Ayisyen (French Creole) ATANSYON: Si nou palé Kreyòl Ayisyen, gen asistans pou sèvis ki disponib nan
lang nou pou gratis. Rele 1-800-439-7247.
繁體中文 (Traditional Chinese) 注意：如果
您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-439-7247.
Tiếng Việt (Vietnamese) CHÚ Ý: Nếu quí vị nói Tiếng Việt, dịch vụ thông dịch của chúng tôi sẵn sàng phục vụ
quí v
ị miễn phí. Gọ
i s
ố
1-800-439-7247.
Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги
перевода. Звоните 1-800-439-7247.
1-800-439-7247
.
ﺔﯾﺑرﻌﻟا (Arabic)
ﻰﻠﻋ ﻞﺼﺗإ ً ﺎﻧﺎﺠ
َ
ﻣ ﻚﻟ ةﺮﻓﻮ
َ
ﺘ
ُ
ﻣ ﺔﯾﻮ
َ
ﻐ
ُ
ﻠﻟأ ةﺪ
َ
ﻋﺎﺴ
ُ
ﻤﻟأ تﺎﻣ
َ
ﺪ
َ
ﺧ ، ﺔﯿﺑﺮﻌﻟأ ِ ﺔﻐ
ُ
ﻠﻟأ ﻢﻠﻜﺘﺗ ﺖﻧأ اذإ :هﺎﺒﺘﻧإ
មែរ (Cambodian)  ,   
 
 1-800-439-7247
Français (French) ATTENTION: Si vous parlez français, des services d'aide
linguistique vous sont proposés
gratuitement. Appelez le 1-800-439-7247.
Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza
linguistica gratuiti. Chiamare il numero
1-800-439-7247.
한국어 (Korean) '알림
': 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
1-800-439-7247. 번으로 전화해 주십시오.
ελληνικά (Greek) ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, υπάρχουν στη διάθεσή σας δωρεάν υπηρεσίες γλωσσικής
υποστήριξης. Καλέστε 1-800-
439-7247.
Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej.
Zadzwoń pod numer 1-800-439-7247.
ह द
ी (Hindi)  


  1-800-439-7247.
 (Lao) :


 , 



, 


,

  . 
1-800-439-7247.
Notice of Right to Reasonable Accommodation
A Reasonable Accommodation is intended to provide persons with disabilities equal opportunity to participate
in the Housing Choice Voucher program through the modification of policies and procedures. New Hampshire
Housing is obligated to make an accommodation that is reasonable, unless doing so would result in an undue
hardship or fundamental alteration in the nature of the housing program.
If you are a person with a disability, and if your request is reasonable, we will try to accommodate your
request. New Hampshire Housing will respond to your request within 30 days.
To obtain a Reasonable Accommodation Request form:
• Call 1-800-439-7247
• People who are hard of hearing can use the TDD line at 603-472-2089 or the NH Relay Number: 711.
TTY or Voice: 711 or 800-735-2964 or 800 676-3777. Español: 800-676-4290.
• Write to New Hampshire Housing, PO Box 5087, Manchester, NH 03108.
• Visit our website at: www.nhhfa.org
If you need help filling out a Reasonable Accommodation Request form, or if you would like to submit a
request in some other way, please let us know. Any information you provide will be kept confidential.
Page 1 1/2021
Housing Choice Voucher (HCV) Rental Assistance Application
Social Security Number: Date of Birth:
Name: (Head of Household)
(Last) (First) (Middle Initial)
Mailing Address:
(Street Address) (City) (State) (Zip)
Home Phone: Cell: Other:
Street Address (if different from mailing address):
(Street) (City) (State) (Zip)
************************************************************************************************************
1. Total number of people living in your house:
2. Gross annual household income is: $ (list yearly income for all household members before taxes)
3. Number of adults over age 18:
4. Number of dependents under age 18:
5. Are you elderly (over 62 years of age)? Yes No
6. Are you, your spouse or co-head a person with disabilities? Yes No
7. Do you speak English? Well Not Well Not at all
8. Do you speak another language other than English at home? Yes No
9. What language do you speak if you do not speak English well?
10. What is your gender?
11. Name of spouse or co-head:
**List the name(s) of all people who will live in the unit:
12. Are any members of your household subject to lifetime registration under a State sex offender law?
If yes, name of family member: Yes No
13. Please check all that apply:
White
Black/African American
American Indian/Alaska Native
Asian
Native Hawaiian/Other Pacific Islander
14. Please check one: Hispanic or Latino Non-Hispanic or Non-Latino
******************************************************************************************
Head of Household Signature Date Spouse, Co-head, Other adult Date
Other Adult Signature Date Other Adult Signature Date
NHHFA use: FIT Way Home Vet DHHS NED M17 FUP Preference: 1 2 3 5 7
BR: PBV: BF MR:
Page 2 1/2021
Head of Household name: SS#: XXX-XX-
If you feel you qualify for any of these preferences or programs, please check below.
Preferences:
1. A member of the household has a terminal illness (death will result within 24 months as verified by a
physician). Which household member has a terminal illness?
2. A member of the household is eligible for services through the Choices for Independence Program (CFI).
Which household member qualifies for CFI?
3. A household member qualifies for a preference as an individual transitioning out of a nursing home or an
institution. Which member qualifies for transitioning out?
4. I am/we are rent burdened or at risk of becoming homeless
• I/We pay more than half of my/our gross income toward rent, or
• I/We live in a shelter and lack a fixed, regular and adequate nighttime residence or primary night
time residence, or
• I/We live with friends or relatives. My name is not on the lease. If I were not in this current living
arrangement, I would otherwise be homeless, or
• I/We am/are temporarily living in a substandard living situation; i.e., campground or other
temporary placement.
5. I am a victim of domestic violence, dating violence, sexual assault or stalking.
6. A household member currently serves in the US armed forces or has been discharged with an honorable
discharge or a discharge based on a service-related injury, illness or disability.
Preferences or Programs Through Agency Referrals: Attach referral to be listed with this preference or program.
7. I am/we are eligible for a Transitional Housing voucher through FIT, The Way Home or Harbor Homes.
Agency referral required.
8. I am/we are eligible for a DHHS Transitional voucher as a person transitioning from an institution and am
in a program receiving case management services through DHHS. Agency referral required.
9. Family Unification Program (FUP): Do you fall into one of these two categories?
*****A DCYF referral must be attached to the application to be listed with this special program.
a. We are a family working with DCYF for whom the lack of adequate housing is the primary reason that
our children will be placed in out-of-home care or their return is being delayed for that reason, or
b. I am a youth at least 18 years of age and not yet 25 years of age who left foster care or will leave foster
care within 90 days and I am homeless or at risk of becoming homeless.
Other:
10. The head of household, spouse or co-head is under age 62 and a person with disabilities.
11. Mainstream Program: Any person with disabilities in the household over 18 and under 62 who qualifies for a
preference within this program because they are:
a. transitioning out of institutional or segregated settings, or are
b. at serious risk of institutionalization because lack of access to supportive services for independent
living, or they would be institutionalized if their services were cut, or
If you do not qualify for the preferences “a” or “b” above, check off “c” below if:
c. you have a person with disabilities in your household who is over 18 years of age and under 62.
Head of Household name: SS#: XXX-XX-
Moderate Rehabilitation Property Option:
The following Mod Rehab properties have vacancies from time to time. If you choose to live in one of these units, you will
pay 30% of your monthly adjusted income. The Mod Rehab program is not tenant based so you cannot take your assistance
with you if you move. You may remain on the Housing Choice Voucher waiting list while living in one of these units. If
your name reaches the top of the Housing Choice Voucher waiting list during the first year of your lease, you will be placed
back on the waiting list to wait for the next opportunity.
No
te: If you choose to live in a Mod Rehab unit it may affect your preference status.
I
f you would like notification of vacancies for a specific property, please place a check mark in the box. Check as many as
you wish. Choosing to be notified does not affect your status on the Housing Choice Voucher waiting list.
Properties with Elderly 62+/ disabled
are available to applicants 62+ or
applicants with disabilities under 62
Location
Property
0 Bedroom
1 Bedroom
2 Bedroom
3 Bedroom
Franklin (8)
Central Street
2 Bedroom
3 Bedroom
Manchester (9)
School & Third Street
1 Bedroom
2 Bedroom
3 Bedroom
Hinsdale (14)
Post Office Square
1 Bedroom – Elderly 62+/disabled
Raymond (15)
Main Street
0 Bedroom – Elderly 62+/disabled
1 Bedroom – Elderly 62+/disabled
Hinsdale (20)
Todd Block
1 Bedroom
2 Bedroom
Farmington (22)
Crowley Street
1 Bedroom – Elderly 62+/disabled
Bristol (24)
Central Square
1 Bedroom - (through West
Central Behavioral Health)
Claremont (29)
High Street
2 Bedroom
Winchester (30)
Keene Road
1 Bedroom – Elderly 62+/disabled
Nashua (31)
Summer Street
Page 3
1/2021
OMB Cont
rol # 2502-0581
Exp. (
02/28/2019)
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
Inst
ructions: 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.
Applicant Name:
Mailing Address:
Telephone No: Cell Phone No:
Name of Additional Contact Person or Organization:
Address:
Telephone No: Cell Phone No:
E-Mail Address (if applicable):
Relationship to Applicant:
Reason for Contact: (Check all that apply)
Emergency
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.
Check this box if you choose not to provide the contact information.
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. 3501-3520). 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.
Privac
y 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 (07/2020)
Page 4
click to sign
signature
click to edit
Page 5 1/2021
Head of Household name: SS#: XXX-XX-
Project Based Voucher Option:
The following properties have a set number of units that have a subsidy attached to them. A tenant living in one of the assisted units will
pay 30% of their monthly adjusted income. The owner handles tenant selection from a separate waiting list for each property and will
contact you directly to determine your eligibility for any vacancies. If you are interested in being placed on one of the specific
property waiting lists, please place a check mark on the line for that property. Choosing to be on the waiting list for a specific
property under this Project Based Assistance Program does not affect your status on the regular Housing Choice Voucher waiting list.
Properties labeled “Elderly 62+” are
designated housing for older persons
and applicants must be 62 or over.
Location
Property
1 Bedroom – Elderly 62+
1 Bedroom barrier free/accessible/62+
Amherst (37)
Parkhurst Place
1 Bedroom – Elderly 62+
1 Bedroom barrier free/accessible/62+
Pelham (38)
Pelham Terrace
2 Bedroom
Rochester (39)
Brookside Place
1 Bedroom
2 Bedroom
Dover (40)
Bellamy Mill
1 Bedroom
2 Bedroom
West Swanzey (41)
West Swanzey Family Housing
2 Bedroom
Lebanon (42)
Upper Valley Transitional
3 Bedroom
3 Bedroom barrier free/accessible
Farmington (43)
Mad River Apartments
1 Bedroom – Elderly 62+
1 Bedroom barrier free/accessible/62+
2 B
edroom – Elderly 62+
Deerfield (44)
Sherburne Woods
2 Bedroom
2 Bedroom barrier free/accessible
3 B
edroom
3 Bedroom barrier free/accessible
Penacook (2, 3 Bedroom) (45)
Concord (3 Bedroom) (45)
Willow Crossing
2 Bedroom
3 Bedroom
Belmont (50)
Sandy Ledge
2 Bedroom
3 Bedroom
Winchester (51)
Snow Brook
1 Bedroom
2 Bedroom
3 Bedroom
Hinsdale (104)
Hinsdale School
Page 6 1/2021
1 Bedroom – Elderly 62+
Eligible for Choices for
Independence (CFI) Program
.
1 Bedroom barrier free/accessible /62+
Berlin (285)
Notre Dame Senior Housing
1 Bedroom – Elderly 62+
1 Bedroom barrier free/accessible/62+
2 Bedroom – Elderly 62+
Conway (344)
Conway Pines Senior
1 Bedroom – Elderly 62+
1 Bedroom barrier free/accessible/62+
Keene (345)
Westmill Senior
1 Bedroom
1 Bedroom barrier free/accessible
Eligible for Chronically
Homeless Preference.
Attach
Upper Valley Haven agency
referral form.
I am/we are rent burdened or
at risk of becoming homeless
.
Lebanon (351)
Parkhurst Community Housing
1 Bedroom – Elderly 62+
1 Bedroom barrier free/accessible/62+
Hampton Falls (354)
The Meadows at Grapevine Run
1 Bedroom – Elderly 62+
1 Bedroom barrier free/accessible/62+
Rochester (357)
Arthur H. Nickless Jr. Housing for
the Elderly
1 Bedroom – Elderly 62+
Eligible for Choices for
Independence (CFI) Program
.
*All units are barrier free/accessible/62+
Laconia (368)
Sunrise House
Single Room Occupancy (SRO)
Veteran Plymouth (373) Bridge House
1 Bedroom – Elderly 62+
1 Bedroom barrier free/accessible/62+
Gilford (363)
Gilford Village Knolls 3
1 Bedroom
1 Bedroom barrier free/accessible
Eligible for Homeless
Preference. Attach Concord
Coalition to End Homelessn
ess
referral form.
Concord (383) Green Street Apartments
2 Bedroom
2 Bedroom barrier free/accessible
Eligible for Homeless
Preference. Attach Strafford
County Community Actio
n
Pa
rtnership of Strafford County
Rochester (387)
Academy Street Family Housing
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.
NOTICE TO APPLICANTS AND PARTICIPANTS OF THE FOLLOWING HUD RENTAL ASSISTANCE PROGRAMS:
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
DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS
OMB No. 2577-0266 Expires 10/31/2019
08/2013
Form HUD-52675
Page 7
2
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
correct.
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
08/2013
Form HUD-52675
Page 8
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Completed 8 February 2021

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