Fillable RENTAL SUBSIDY RECERTIFICATION PACKAGE (Includes the following programs: (City of New York)

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RENTAL SUBSIDY RECERTIFICATION PACKAGE (Includes the following programs: (City of New York)

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RENTAL SUBSIDY RECERTIFICATION PACKAGE
(Includes the following programs: Housing Choice Voucher, Shelter Plus Care, and SRO MOD Rehab)
Dear Rental Subsidy Participant:
As a participant in the New York City Department of Housing Preservation Rental
Subsidy program, federal regulations require that you recertify annually in order to continue to receive
assistance. Please:
Read and complete the top of each page in this package.
Rental Subsidy Participant Household Summary.
Have all household members 18 years or older sign:
o Form 1)
o )
Complete all forms that apply to your household (Forms 3-11)
Read and complete Checklist
Read, sign, and date the certification statement below.
Make a copy of this package for your records
Obtain a receipt by bringing the package to 100 Gold Street or mailing the package via certified mail.
If you need additional copies of any forms, please make copies as needed or obtain copies from 100
Gold Street, Room 1-0 or at the following web address:
https://www1.nyc.gov/site/hpd/section-8/about-section-8.page
Certification Statement
I have read the enclosed HPD Rental Subsidy annual recertification forms and instructions. I have
completed my recertification with the most current information on my household’s income, assets
and family composition. I understand that providing false statements to a government agency is
punishable under federal law and may result in the termination of my participation in the Rental
Subsidy program. I further understand that HPD will verify my income information with a third party,
such as the Enterprise Income Verification database.
___________________________________ _______________________
Head of Household Signature (Required) Date (Required)
Return Completed Package to:
NYC Dept. of Housing Preservation and Development
Division of Tenant Resources (DTR)
Project-Based Programs Unit
100 Gold Street, Room 4N
New York, NY 10038
Office of Housing Operations
DIVISION OF TENANT RESOURCES
Case Manager’s Name
Complete Package Due On or Before
(late packages may result in termination):
Need help?
Call HPD at 917-286-4300. For more
HCV Section 8

Administrative Plan at
http://www.nyc.gov/html/hpd/html/tenan
ts/section_8.shtml.
Did Someone Other than an HPD Employee
Help You Complete This Recertification
Package?
Name __________________
Relationship to You_____________________
Phone # __________________
Address ______________________
Email _____________
Head of
Household Name:
Address:
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signature
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Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY NUMBER (last 4
digits)
RENTAL SUBSIDY PARTICIPATING HOUSEHOLD SUMMARY
Do you need assistance in any other language besides English? □Yes □ No
If Yes, list the language: ________________________________
Last Name
First Name
Daytime Phone Number(s)
_______________________
Apartment
City
State
Zip Code
Email Address
FAMILY MEMBERS
Household composition must be verified at every recertification and throughout the year if it changes.
Please list all household members below and enter the requested information. If there are any changes in
the household from the last annual recertification, please provide HPD with supporting documentation.
              
Household Member(Form 13). If you would like to request to add a household member, please fill out
(Form 12).
FULL NAME
FULL-TIME
STUDENT
SOCIAL
SECURITY
NUMBER
AGE
DATE
OF BIRTH
CITIZENSHIP
IS THIS PERSON
DISABLED?
□ Yes
□ No
□ Yes
□ No
□ Yes
□ No
□ Yes
□ No
□ Yes
□ No
Please enter all the requested information below. Please provide the supporting documentation described
in each section.
THIS FORM MUST BE COMPLETED BY THE HEAD OF HOUSEHOLD.
The Head of Household is responsible for all information reported on behalf of household members.
Eligible Citizen
Eligible Citizen
Eligible Citizen
Eligible Citizen
Eligible Citizen
No
No
No
No
No
Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY NUMBER (last 4
digits)
HOUSEHOLD INCOME INFORMATION
Household income must be reported and verified at every recertification. All income in the
household must be reported and verified. Please enter all household income below and provide
HPD with supporting documentation. Supporting documentation as listed on Forms 3 and 4 must
be provided for correct income listed below and for any corrections written. Any new income to
the household must be listed on Form 3.
FULL NAME
INCOME
DESCRIPTION
FREQUENCY
AMOUNT
ANNUAL INCOME
HOUSEHOLD ASSETS OTHER THAN REAL ESTATE PROPERTY
All assets in the household must be reported and verified at every recertification. If any of the information
below is incorrect, please write the correct information on the lines provided, along with the supporting
documentation as listed in     ). If you no longer have an asset that was
previously reported to HPD please provide documentation, such as a closing statement or a letter of
transfer from your bank. If you have a new asset, please add below and use the Verification of
Assets Form. If you leave this section entirely blank, you will be declaring to HPD that your
household has no assets.
FULL NAME
DESCRIPTION
OF ASSET ACCOUNT NUMBER
AMOUNT
ANTICIPATED INCOME
(e.g., interest)
Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY NUMBER (last 4
digits)
REAL ESTATE PROPERTY
Households must report the ownership of any real estate property at every recertification. Please list all
properties to which a family has ownership interest and complete the Real Estate Declaration form which
can be found at (http://www1.nyc.gov/site/hpd/section-8/about-section-8.page). If you no longer own real
estate property listed below, please fill out the appropriate boxes.
Is any property a Cooperative (Co-op)?
Do you collect rent from this property?
Yes No
Is any of the property you own your primary residence?
NAME(S) OF PROPERTY
OWNER(S)
ADDRESS OF PROPERTY
PROPERTY
VALUE
ANTICIPATED
INCOME (e.g. rental
income)
IF YOU HAVE SOLD OR DISCARDED PROPERTY SINCE ADMISSION TO THE PROGRAM OR YOUR LAST
CERTIFICATION, COMPLETE THE SECTION BELOW: INCOME FROM SALE
NAME(S) OF PROPERTY
OWNER(S)
PROPERTY ADDRESS
SALE PRICE
PROFIT EARNED
Yes No
Yes No
Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY NUMBER (last 4
digits)
MEDICAL EXPENSES
If the Head of Household or spouse is 62 years of age or older or has a documented disability, you may
declare un-reimbursed medical expenses by filling out "Declaration of Un-reimbursed Medical and
Pharmacy Expenses" (Form 6). Please fill out this form even if your expenses have not changed. Please
list below any qualified medical expenses and provide HPD with supporting documentation.
FULL NAME OF
FAMILY MEMBER
DESCRIPTION OF
EXPENSES
PERIODIC
FREQUENCY
PERIODIC
AMOUNT
ANNUAL AMOUNT
DISABILITY EXPENSES
If you or a household member has a documented disability, you may declare un-reimbursed disability
expenses by filling out "Declaration of Un-reimbursed Disability Expenses" (Form 7). Please fill out this
form even if your expenses have not changed. Please list below any qualified disability expenses and
provide HPD with supporting documentation.
FULL NAME OF
FAMILY MEMBER
DESCRIPTION OF
EXPENSES
PERIODIC
FREQUENCY
PERIODIC
AMOUNT
ANNUAL AMOUNT
Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY NUMBER (last 4
digits)
Has any adult household member been registered as a lifetime sex offender since Rental Subsidy
Housing assistance at HPD began? Yes No
If Yes, it is required that you list the name of the household member: ________________________________
CHILDCARE EXPENSES
If you have un-reimbursed childcare expenses, please refer to "Verification of Childcare Expenses" on
(Form 10) to see if you qualify for this deduction. Please fill out this form even if your expenses have
not changed. Please list below any qualified child care and provide HPD with supporting
documentation.
CHILD’S FULL NAME
FREQUENCY
AMOUNT
ANNUAL AMOUNT
UTILITY ALLOWANCE
Utility allowance must be verified at every recertification. If any of the information below is incorrect,
please provide HPD with a utility bill.
UTILITY
PAID BY OWNER (yes or no)
PAID BY TENANT (yes or no)
Gas
Electric
Heat and hot water
No
No
No
No
No
No
Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY NUMBER (last 4
digits)
FORM 1. AUTHORIZATION FOR THE RELEASE OF INFORMATION / PRIVACY ACT NOTICE
In order to complete or verify an application for participation and to maintain continued assistance in the Rental Subsidy
program, this consent form authorizes the release of information necessary to permit HUD and HPD to obtain:
1. Information from SWICAs (State Wage Information Collection Agencies, such as a Labor Department)
2. Salary and wage income information from previous or current employers and unearned income information (such as
interest and dividend payments) from banks or other financial institutions
3. Information such as but not limited to:
Income from public or private pension funds, unemployment compensation, worker's compensation income,
disability payments, military pay, alimony, child support, and private contributions; information related to
school attendance verification and the receipt of financial grants from entities, credit agencies, or
government agencies, including but not limited to the:
NYC Human Resources Administration, NYC Office of Payroll Administration, NYC Department of
Finance, NYC Department of Health and Mental Hygiene, NYC Clerk's Office, NYS Department of Motor
Vehicles, Courts and NYS Office of Court Administration, NYS Department of Labor, and U.S. Department of
Veterans Affairs
4. Information from the Social Security Administration (SSA) for the purpose of verifying Social Security numbers and income
information
5. Tax return information from the Internal Revenue Service (IRS)
The authorization to release information specified by this consent form expires 15 months after the date that the
form is signed. Photocopies of this consent form shall be as valid as the original.
CONSENT: I consent to allow HUD and HPD to request and to obtain income information from the sources listed on this
                 
programs. I understand that HPD will not use information obtained by this consent to deny, reduce, or terminate
assistance without first independently verifying the accuracy of this information. In addition, I must be given an
opportunity to contest those determinations.
PRINT NAMES OF ALL FAMILY
MEMBERS AGE 18 OR OLDER
DATE OF
BIRTH
SOCIAL
SECURITY
NUMBER
SIGNATURE
DATE
PRIVACY ACT NOTICE: Authority: 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. Purpose: Your income and other information collected by HUD and HPD is used to
determine your eligibility for Rental Subsidy assistance, the appropriate bedroom size of your voucher, and the amount that your family will pay toward rent and utilities.
Other Uses: HPD 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 informa tion 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 or HPD,
except as permitted or required by law. Penalty: You must provide all of the information requested by HPD, including all Social Security numbers that you and all other
household members ages six years or older have and use. Providing the Social Security numbers of all household members 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 r ejection of your eligibility approval.
The Head of Household and all family members 18 years of age or older must sign a consent form according to
federal law (42 U.S.C. § 3544) and U.S. Department of Housing and Urban Development (HUD) regulation (24 CFR §
5.230). 
subsidy.
This consent authorizes HUD and HPD to obtain information directly from third party sources in order to verify the
income, the value of assets, expenses related to deductions from income (including medical, pharmaceutical and
day care expenses), family composition information, and related information for each household member. HUD
and HPD will use the information received for the purposes of determining whether your family is eligible for
Rental Subsidy benefits and to ensure that these benefits are set at the correct level.
EACH HOUSEHOLD MEMBER 18 YEARS OF AGE OR OLDER MUST COMPLETE AND SIGN THIS FORM.
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Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY NUMBER (last 4
digits)
FORM 2. DECLARATION OF EMPLOYMENT STATUS
Each member of the household 18 years of age or older is listed in the table below and is required
to declare his or her employment status. If the household member is unemployed, indicate the last
date of his or her employment. In a, check “YES” if any
of the following apply:
Household member is employed part time or full time
Household member is self-employed or seasonally employed
Household member is employed in any way and is a student
Check “No” if:
Household member is not currently employed part time or full time
Household member is not currently self-employed or seasonally employed
Household member is not employed and is either retired or has a disability
Each member must sign and date the last column. If any member became unemployed within
the last two years, list the name and contact information for the employer at the bottom of the page.
The first line has been completed as an example.
TO BE COMPLETED AND SIGNED BY EVERY HOUSEHOLD MEMBER 18 YEARS OLD OR
OLDER.
FULL NAME
Are you employed?
Last date of
employment - if
not employed
Signature
Date
Example:
Jane Brown
x Yes □ No
n/a
Jane Brown
11/22/09
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
If any household member lost his or her employment in the previous two years, please list the household
name as well as the phone number, and address of the former employer in the space below.
_________________________________________________________________________________
_________________________________________________________________________________
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Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY NUMBER (last 4
digits)
FORM 3. DECLARATION OF ALL INCOME
INCOME SOURCES
Employment: Please indicate the amount you or a household member receives from employment.
Provide six weeks of consecutive paystubs or a verification letter on letter head from your employer
stating amount and frequency of pay. You may also have completed
by your employer.
Social Security / SSI: Please indicate the amount you or a household member currently receives. HPD

Public Assistance: Provide a verification letter which states the amount of benefits paid.
Child Support / Alimony: Provide official documentation or a letter from the absent parent showing the
frequency and amount of child support and/or alimony payments.
Disability: Provide official documentation of frequency and amount of disability payments.
Unemployment / : Provide official documentation of the frequency and amount

Pension / Retirement: This category includes IRA distributions that must be reported. Provide official
documentation of the frequency and amount of pension/ retirement income.
: Provide official documentation of the frequency and amou
pay.
Financial Aid/ Scholarship: Provide official documentation from the source of educational financial
aid/scholarship with the amount and frequency of money received.
Real Estate: Please provide documentation of any income you receive from owning real property (e.g.,
rental income, income earned from the sale of property, etc.)
Self-employment / Seasonal employment: If you are self-employed, a seasonal employee or have had
more than one employer in the past 12 months, provide a complete signed copy of your most recent tax
return.
Other Types of Support: If a household member receives any regular income from organizations or
persons (including relatives and friends) not residing in your home, provide documentation of such
support. For example, a signed statement from the person or agency providing the income, verifying
the amount and frequency.
The Head of Household must complete the form on the following page for
each member of the household who receives any income and provide
documentation. Please first review the definitions and examples of income
listed below and see if they apply to any member of the household.
TO BE COMPLETED AND SIGNED BY HEAD OF HOUSEHOLD.
Have you completed
this form?
Yes
□
Not
Applicable
□
Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY NUMBER (last 4
digits)
FORM 3. DECLARATION OF ALL INCOME (CONTINUED)
Please refer to the examples of income listed on the previous page. The first line has been filled out
as an example. Household members may be listed on multiple lines if they receive income from
different sources.
NAME OF
HOUSEHOLD MEMBER
OTHER
INCOME SOURCE
START AND
END DATES
AMOUNT
FREQUENCY (CIRCLE ONE)
Example:
Jane Brown
SSI
1/1/10 to
12/31/10
$
771.00
Weekly bi-weekly
monthly yearly
$
Weekly bi-weekly
monthly yearly
$
Weekly bi-weekly
monthly yearly
$
Weekly bi-weekly
monthly yearly
$
Weekly bi-weekly
monthly yearly
$
Weekly bi-weekly
monthly yearly
$
Weekly bi-weekly
monthly yearly
$
Weekly bi-weekly
monthly yearly
$
Weekly bi-weekly
monthly yearly
$
Weekly bi-weekly
monthly yearly
$
Weekly bi-weekly
monthly yearly
I certify that the above information is accurate and understand that providing false statements to a
government agency is punishable under federal law and may result in loss of subsidy.
_______________________________________________
______________________________
SIGNATURE OF HEAD OF HOUSEHOLD DATE
Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY
NUMBER
(last 4
digits)
FORM 4. VERIFICATION OF WAGES
SECTION A (to be completed by EMPLOYEE)
Name of Employee: ____________________________ Social Security Number: _______________
SECTION B (to be completed by EMPLOYER)
Company:___________________________ Address: _____________________________________
Employer Representative: ______________Title: ________________ Telephone: _________________
Type of Income Amount
Pay Frequency
(Hourly, Bi-weekly, Monthly,
Annual)Write in Below
Average hours worked per
pay
period
Current gross wages: $
Gross wages in the past 12 months $
Overtime: $
Bonus, commission, or tips: $
Armed Forces wages for exposure
to hostile fire:
$
Future gross wages:
(If wages are expected to increase,
please indicate date effective:
_____/_____/_____)
$
If wages for employee are seasonal, sporadic, or cannot be accurately captured in the above chart, please
explain: __________________________________________________________________________
Original hire or rehire date: ________________________ Date of termination: _________________________
COMPANY STAMP/SEAL IS MANDATORY
The purpose of this form is to verify the wages of each household member.
Each employed household member mu
st complete this form if the below are
not available:
• Recent consecutive pay stubs stating gross wages (2 if paid monthly, 3 if
paid bi-weekly, 6 if paid weekly)
• Letter from employer stating gross wages and work hours
SECTION A TO BE COMPLETED BY EMPLOYED HOUSEHOLD MEMBER
SECTION B TO BE COMPLETED, STAMPED AND SIGNED BY CURRENT
EMPLOYER
Have you completed
this form?
Yes
Not
Applicable
I certify that the above information is accurate and understand that providing false statements to a
government agency is punishable under federal law.
_______________________________________________
______________________________
SIGNATURE OF OFFICIAL DATE
Hourly
Hourly
Hourly
Hourly
Hourly
Hourly
65363
DivisionofTenantResources
HEADOFHOUSEHOLDNAME
SOCIALSECURITYNUMBER
(last4digits)
202010
WHATISANASSET?
An asset is something you own that youcanconvert into cash, such as bank accounts, real estate,stocks and
bonds.Ifyouoranyhouseholdmember,includingchildren,ownsanyofthetypesofassetslistedbelow,youmust
declarethemintheParticipatingHouseholdSummarypageofthisrecertificationpackage.Additionally,youmust
submit documents verifying the value of the asset(s) and income earned from the asset if applicable. Failure to
report assets may result in termination or denial of subsidy. Below is a list of different types of assets and their
descriptions.
TOBEREVIEWEDBYHEADOFHOUSEHOLD
ASSETSOURCES
Bank
Accounts:Anyaccountthatisopenwithanybalanceatanybankwhetherindividuallyorjointly
owned.Examplesarechecking,saving,moneymarketaccounts,andcertificatesofdeposit.Providea
verificationletteronletterheadfromyourfinancialinstitution,providethemostrecentbankstatement,
orhaveaForm5.VerificationofAssetsformcompletedbythefinancialinstitution.
InvestmentAccounts:Examplesofinvestmentsaccountsarestocksandbonds.Provideofficial
documentationstatingthevalueandanydividendsearnedontheaccountorthemostrecentstatement
fromthefinancialinstitution.
EquityinRealEstateProperty:Equityinrealpropertyistheestimatedmarketvalueofanyproperty
ownedlesstheunpaidbalanceonloanssecuredbytheasset.Providepropertytaxstatementsand
mortgagestatementsifapplicable.
RetirementSavingsAccounts:Aformalaccountthatenablesyoutosetasidemoneytobespentafter
retirement.Examplesofthistypeofaccountinclude,IRA,Keoghand401Kplans.Provideofficial
documentationstatingthevalueandanydividendsearnedontheaccountorthemostrecentstatement
fromthefinancialinstitution.
Company
RetirementorPensionAccounts:(Ifanymemberofthefamilyhasaccesstomaking
withdrawals.)Provideofficialdocumentationoffrequencyandamountofpayments.
Lumpsumpayment:Aonetimepaymentthatisretainedandcanbeverified.Examplesoflumpsum
paymentsareInheritances,insurancepayments,orsettlements.Provideofficialdocumentationofthe
valueofthepaymentandanyinterestincomeearned.
Personalpropertyheldasinvestment:Anyobjectorcollectionofvaluethatcanbeconvertedintocash.
Examplesofthisincludecoincollection,recreationalvehicles,jewelry,etc.Provideofficial
documentationofthevalueofthepropertyandanyoutstandingdebt.
Additionalexamplesofassets:Examplesofadditionaltypesofassetsincludecashvalueoflife
insurance,cashvalueoftrusts,Annuities,Scorporation,partnerships,andtime-shares.Documentation
verifyingthevalueoftheseassetsmustbeprovided.
Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY
NUMBER
(last 4
digits)
FORM 5. VERIFICATION OF ASSETS
SECTION A (To be completed and returned by Head of Household, if applicable)
I certify that no one in my household has a savings account, checking account, IRA, CD or stocks/bonds
Signature (Head of Household):__________________________________ Date: _________________
SECTION B (To be completed by financial institution for each household member with assets)
Type of Asset
(savings, checking
or retirement
account, stocks,
CDs, etc.)
Account Number
Current
Balance
Early Withdrawal
Fees or Penalties
(if any)
Current
Rate of
Interest/
Number of
Shares
Is This a Joint Account/Asset?
Yes/
No
Joi
nt Asset
Holder’s Name
Financial Institution: ________________________ Address _______________________________
Representative:___________________________ Title: _____________Telephone: _________________
COMPANY STAMP/SEAL IS MANDATORY
The purpose of this form is to provide third party verification of each household
member’s assets. Assets are ite
ms of value that may be turned into cash and may
include savings accounts, checking accounts, IRA accounts, Certificates of Deposit
(CDs), and stocks/bonds. Each household member must provide bank statements
or other evidence of assets provided by the financial institution. If these
statements are not available, each member must have their financial institution
complete this form.
• If an asset holder has unverified assets from more than one financial
institution, a separate form should be used for each financial institution.
• If assets reported on this form are joint assets, one form may be submitted for
the joint asset holders.
SECTION A TO BE COMPLETED BY HEAD OF HOUSEHOLD, AND RETURNED IF
NO MEMBER OF THE HOUSEHOLD HAS ASSETS
SECTION B TO BE COMPLETED, STAMPED AND SIGNED BY FINANCIAL
INSTITUTION
FOR EVERY MEMBER OF
THE HOUSEHOLD
WITH
ASSETS
Have you completed
this form?
Yes
Not
Applicable-
(Complete
Section A)
Name of Social
Asset Holder __________________________________ Security Number _________________________
I certify that the above information is true and correct as of _____________________ (date). I
understand that providing false statements to a government agency is punishable under federal law.
_______________________________________________
______________________________
SIGNATURE OF OFFICIAL DATE
Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY
NUMBER
(last 4
digits)
FORM 6. DECLARATION OF UN-REIMBURSED MEDICAL & PHARMACY EXPENSES
Is Your Household Eligible for a Medical Expense Deduction?
1. Do you have any un-reimbursed pharmacy expenses? Yes No
2. Do you pay a Medicare premium or pay for medical insurance? Yes No
3. Is any family member currently paying off past medical bills? Yes No
4. Is there an anticipated medical expense during the next 12 months? Yes No
If you answered yes to any of the questions above, please complete the box below:
Name of
Household
Member
Eligible Expense
(
pharmacy, insurance
premiums, dental,
hearing aid, eyeglasses,
medical equipment)
Amount Due, Paid in
the Past, or
Expected in the
Next 12 Months*
(Submit proof of
payment or invoice)
Expense
Date or
Payment
Frequency
(monthly,
annually, etc.)
Name and Phone
Number of
Institution
Providing Service
*If copies of cancelled checks, receipts, or statements from an insurance company are not available, you may submit
a statement from your doctor, pharmacist, or other medical-related service provider specifying the nature and amount of
expenses expected in the next 12 months. Only the portion of the total medical expense that exceeds 3% of the
household annual income is an allowable deduction.
If the Head of Household, co-head, or spouse is disabled, and/or 62
years of age or older and has un-
reimbursed (not already paid for by
someone other than yourself) medical or pharmacy expenses, please
complete this form for each household member with medical or pharmacy
expenses. You must submit verification of all un-reimbursed medical and
pharmacy expenses incurred during the last 12 months if they are expected
to be an expense in the upcoming year. This includes copies of cancelled
checks, receipts, or statements from an insurance company. Please submit
a pharmacy printout for any un-reimbursed prescription payments you have
made in the past 12 months.
TO BE COMPLETED AND SIGNED BY THE HEAD OF HOUSEHOLD
Have you completed
this form?
Yes
Not
Applicable
I certify that the above information is accurate and understand that providing false statements to a
government agency is punishable under federal law and may result in loss of subsidy.
_______________________________________________
SIGNATURE OF HEAD OF HOUSEHOLD
______________________________
DATE
Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY
NUMBER
(last 4
digits)
FORM 7. DECLARATION OF UN-REIMBURSED DISABILITY EXPENSES
Is Your Household Eligible for a Disability Expense Deduction?
1. Do you pay for someone to care for a disabled person in your household? Yes No
2. Did you buy medical equipment for a disabled person in your household? Yes No
3. Were you or any another household member able to earn income from a job because of this disability
expense? Yes No
If you answered yes to question #3 above, please complete the boxes below:
Note: Only the portion of the to
tal disability expense that exceeds 3% of your household annual income is an
allowable deduction. The deduction for the disability expense may not exceed the total amount of money earned by
the household member(s) who are able to work because of the disability expense.
If your family has an un-reimbursed expense for attendant care (home health aid
for a disabled adult or baby-sitter for a disabled child age 13 or older) or medical
equipment (such as a wheelchair) for a household member who is disabled
and as a result of this expense, you or any household member were able to earn
income from a job, you should complete this form. You must submit verification
of any disability expenses incurred during the last 12 months. This may include
a receipt for a wheelchair, ramp, adaptation to a vehicle, or special equipment
to enable a blind person to read and write.
TO BE COMPLETED AND SIGNED BY THE HEAD OF HOUSEHOLD
Have you
completed
this form?
Yes
Not
Applicable
Name of disabled
household member:
Name of disabled
household member:
1.__________________________
2.________________________
Eligible disability expense(s):
(medical equipment or attendant
care expense)
Amount due or expected in the
next 12 months: (Submit proof
of recurring payments or invoice)
Name(s) and phone number of
institution(s) providing
service:
Name(s) of household
member(s) who earned
income as a result of the
disability expense:
I certify that the above information is accurate and
understand that providing false statements to a
government agency is punishable under federal law and may result in loss of subsidy.
_______________________________________________
______________________________
SIGNATURE OF HEAD OF HOUSEHOLD DATE
Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY
NUMBER
(last 4
digits)
FORM 8. VERIFICATION OF STUDENT STATUS
The purpose of this form is to verify student status. Each household member
18 years of age or older who attends school full-time or is in a job training
program must complete this form. If this form cannot be completed, please
provide one of the following to verify student status:
• High school students may submit their most recent report card or a letter
from a school official confirming enrollment
• College students may submit their most recent transcript or a letter from an
official at their college
• Students in adult training programs may submit enrollment documents or a
letter from a program official
THIS FORM MUST BE COMPLETED, STAMPED AND SIGNED BY A
SCHOOL/JOB TRAINING PROGRAM ADMINISTRATOR.
Have you completed
this form?
Yes
Not
Applicable
SECTION A (to be completed by Head of Household)
Student Household Member: ________________________ Social Security Number: _______________
SECTION B (to be completed by School or Job Training Program Administrator)
1. The student named above is enrolled in:
High School/College
Adult Training Program
If you selected “High School/College,” skip #2 and go to #3.
2. Is the program providing employment training and self-sufficiency services?
Yes
No
Is the program funded by the federal, state, or local government?
Yes
No
Is the program funded by HUD?
Yes
No
3.
Enrollment Status:
This student is enrolled in a (check one) full time/ part time program and will earn ______ credits this
semester. Weekly hours of program participation if in an adult training program: ________________
Amount per year
Tuition
Work Study
Grants/Scholarship
Educational Institution: ______________________ Address________________________________
Administrator:___________________________ Title: _____________Telephone: ______________
COMPANY STAMP/SEAL IS MANDATORY
I certify that the above information is accurate and understand that providing false statements to a
government agency is punishable under federal law.
_______________________________________________
______________________________
SIGNATURE OF ADMINISTRATOR DATE
click to sign
signature
click to edit
Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY
NUMBER
(last 4
digits)
FORM 9. VERIFICATION OF ABSENT PARENT(S)
Households with any member under 18 years of age who are living in the
unit without one or both parents must complete this form. If a child has
two absent parents, fill out two lines of the chart for the same child and
submit proof of residence for the child. If you receive any child support, you
must provide an official document or copy of any legal separation
documents. If there is no legal document, provide a letter from the absent
parent stating the amount and frequency of child support provided if any.
THE HEAD OF HOUSEHOLD MUST COMPLETE AND SIGN THIS
FORM.
A child will only be considered part of the household if he or she resides in
the household at least 183 days (over 6 months / 50%) of the year.
Have you completed
this form?
Yes
Not
Applicable
Do you have a written agreement regarding child support as a result of a divorce, court order, or legal
separation from one (or more) of the absent parents?
Yes
No
If Yes, attach a copy to this form;
If No, provide a letter from the absent parent stating amount of child support provided.
Name of Child
First and Last
Name
of Absent Parent
Last Known
Address and
Cell or Home
Phone Number of
Parent
Does the Absent
Parent Contribute
Financially and
How Much?
Does HRA Collect
Money from the
Absent Parent and
How Much?
Yes/
No
Per
Week/Month
Yes/
No
Per
Week/ Month
$
per
$
per
$
per
$
per
$
per
$
per
$
per
$
per
$
per
$
per
$
per
$
per
I certify that the above information is accurate and understand that providing false statements to a
government agency is punishable under federal law and may result in loss of subsidy.
_______________________________________________
___________________________
SIGNATURE OF HEAD OF HOUSEHOLD DATE
N
N
N
N
N
N
N
N
N
N
N
N
click to sign
signature
click to edit
Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY
NUMBER
(last 4
digits)
FORM 10. VERIFICATION OF CHILDCARE EXPENSES
Name of Child
Age
of
Child
Rate of Pay
During
School Year
Rate of Pay
During
School
Vacations
Frequency of Pay
(hourly, daily,
weekly, monthly,
annually)
Monthly
Average
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
If childcare expenses are seasonal, sporadic, or cannot be accurately captured in the above chart, please
explain:___________________________________________________________________________________
____________________________________________________________________________________
Name of Childcare Provider: ______________________ Address: ______________________________
Contact: __________________ Title: _______________Telephone (Required): ____________________
*If child is 13 or older, disabled, and care for child enables an adult household member to be employed,
please complete “Verification of Un-Reimbursed Disability Expenses” (Form 7).
Households who have un-reimbursed childcare expenses should complete
this form if:
o The expenses are for a child or children age 12* or younger and
o The childcare is necessary for a family member to be gainfully
employed or to further his or her education.
THIS FORM MUST BE COMPLETED BY THE HEAD OF HOUSEHOLD
AND
COMPLETED AND SIGNED
BY THE CHILDCARE PRO
VIDER.
Have you completed
this form?
Yes
Not
Applicable
I certify that the above information is accurate and underst
and that providing false statements to a
government agency is punishable under federal law.
_______________________________________________
______________________________
SIGNATURE OF CHILD CARE PROVIDER DATE
FOR HPD USE ONLY
Call to provider
made on ______________ (date) by _________________________________ staff member’s name
Expenses verified? Yes No Notes: __________________________________________
Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY
NUMBER
(last 4
digits)
FORM 11. DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS

    !"##$%%& '(')'*$+,
 +$--.,+//'0  !12& 3 
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 '
            ! 
42 +%)5 #/, (6  +%)5 66+
4(62 )71 8.7+%)5 #6*
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2!2 !(6 
.2 & 3 '
 2 & 39:07:071 2 !2 !
1 1
':072!2 & 3 
2& 3
'!2 ! 2& 3 
+%)5 $'+**'
2& 3 2!1 .1
2& 3 '  
2 !2 & 3 1  1 
'2 !
 +':'
"#$ %&&&' ((#$ " )
 ;1
1((< '
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Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY
NUMBER
(last 4
digits)
FORM 11. DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS
(("'#$ %')
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  2 & 3'0
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'
B  2 & 3 9:07
'2 1?
1 1 2! 
'
2 !   *, '0
2 !12 ! '02!
12 ! > 
'
"''*%&"-& $ # '+'* *($ 
"%&(+"" *$ ""
PRINT NAMES OF ALL
FAMILY MEMBERS AGE 18
OR OLDER
DATE OF
BIRTH
SOCIAL
SECURITY
NUMBER
SIGNATURE
DATE
< '+$--.,+//:>,%?*,?+,"*!+/1+,",!52 & 3.$+/-$
click to sign
signature
click to edit
Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY
NUMBER
(last 4
digits)
FORM 12. REQUEST TO ADD A HOUSEHOLD MEMBER
Complete this form to declare any additions to your household by birth,
adoption, marriage, or domestic partnership or if you would like to request that
any other individuals be added to your household. All proposed additions to
household age 18 and over will be screened for criminal background and sex
offender registration. Failure to get approval from HPD for all proposed
additions other than by birth, adoption, marriage or domestic partnership
may be cause for the termination of Rental Subsidy assistance.
TO BE COMPLETED AND SIGNED BY THE HEAD OF HOUSEHOLD AND
PROPOSED MEMBER
Have you
completed this
form?
Yes
Not
Applicable
_______________________ _____________________ _______________________ _____ ____ ________
LAST NAME FIRST NAME RELATIONSHIP TO SOCIAL SECURITY NUMBER
HEAD OF HOUSEHOLD
____/____/____ Sex: Male Female Are you disabled? Yes No Are you a student? Yes No
BIRTH DATE
Are you employed? Yes No If YES, please complete “Verification of Wages” (Form 4). If NO,
complete “Declaration of All Income” (Form 3).
Declaration of Citizenship Status Citizen Non-citizen with Eligible Immigration Status Non-citizen
who chooses not to declare Eligible Immigration Status
If your status is “Citizen” you must provide documentation if “Non-citizen with Eligible Immigration
Status,” you must include one of the following documents: 1) Alien Registration Card (Form I-551), 2)
Arrival Departure Record (I-94), 3) Temporary Resident Card (I688), or Employment Authorization Card (I-
688B). If “non-citizen who chooses not to declare” household subsidy will be based on the number of
eligible citizens and legal residents in the household.
I certify that the above information is accurate and understand that providing false statements to a
government agency is punishable under federal law and may result in loss of subsidy.
_______________________________________________
______________________________
SIGNATURE OF PROPOSED HOUSEHOLD MEMBER DATE
OR GUARDIAN (IF UNDER 18)
_______________________________________________
______________________________
SIGNATURE OF HEAD OF HOUSEHOLD DATE
Requiredforallproposedhouseholdmembers18yearsofageandolder:
AphotoID,SocialSecuritycardandbirthcertificate
Proofofprioraddress
Asigned“AuthorizationfortheReleaseofInformation”(Form1)
ASigned“DeclarationofEmploymentStatusForm”(Form2)
Documentationofanyincomereceivedbytheproposedhouseholdmember
Requiredforallproposedhouseholdmembersunder18yearsofage:
Legalcustodydocumentsoraletterfromasocialserviceproviderstatingthechildpermanently
resideswiththeHeadofHousehold
AcopyofSocialSecuritycard
Acopyofbirthcertificate
“VerificationofAbsentParent(s)”(Form9)(ifapplicable)
click to sign
signature
click to edit
Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY
NUMBER
(last 4
digits)
FORM 13. REQUEST TO REMOVE HOUSEHOLD MEMBER
To request that any individual be removed from the Rental Subsidy household
composition, please complete this form and provide documentation of the
departing member’s new address (example: copy of the departed/departing
member’s new lease or utility bill). If household member has died, please
provide date of death or a copy of the death certificate.
TO BE COMPLETED BY HEAD OF HOUSEHOLD
Have you completed
this form?
Yes
Not
Applicable
Name of person to remove from Rental Subsidy household composition:
________________________ ___________________ ____________________________
Last Name First Name Social Security Number
I have included the following to remove the above family member from my household:
Lease or utility bill from the departing/departed household member’s new address*, OR
Copy of the death certificate, OR
Date of Death ____________________ (HPD will verify with the Social Security Administration)
*
If a copy of the lease or bill is not available, please explain why:
I certify that the above information is accurate and understand that providing false statements to a
government agency is punishable under federal law and may result in loss of subsidy.
_______________________________________________
______________________________
SIGNATURE OF HEAD OF HOUSEHOLD DATE
click to sign
signature
click to edit
Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY NUMBER (last 4
digits)
RECERTIFICATION PACKAGE CHECKLIST
Please carefully read the instructions for this Recertification Package. This
checklist and the instructions will tell you what forms are required in order
to continue receiving Rental Subsidy rental assistance. In addition to the
cover page and Rental Subsidy Participant Household Summary, there are
twelve (12) forms in the Recertification Package. Please check the last
column of this checklist as you complete each form. If a form does not
apply to your household, you must 
form, and return both the checklist and the form with your package.
TO BE COMPLETED BY THE HEAD OF HOUSEHOLD.
Have you completed
this form?
Yes
□
Form #
Form Name
Who Must Complete this Form
Completed?
Cover
Page
Rental Subsidy
Recertification Package
Cover Page
The Head of Household must sign the cover
page to certify that the package has been
filled out truthfully and completely.

Participant
Household
Summary
Rental Subsidy
Participant Household
Summary
The Head of Household must review and
make corrections to information that was
reported at the last annual certification.

1
Authorization for the
Release of Information/
Privacy Act Notice
Each member of the household age 18 years
and older must sign and date this form.

2
Declaration of
Employment Status
Each member of the household age 18 years
or older must complete, sign and date this
form, indicating his or her employment status.

3
Declaration of All
Income
The Head of Household must complete this
form for each member of the household who
receives income from any source, including
wages, Social Security, Public Assistance,
child support, Disability and Unemployment
Benefits, etc.
□ Yes
□ No
4
Verification of Wages
Each employed member must provide recent
consecutive paystubs (2 if paid monthly, 3 if
paid bi-weekly, 6 if paid weekly) OR have
his or her employer complete this form OR
provide a letter from the employer stating
employment dates and income.
□ Yes, given to
employer
□ N/A
5
Verification of Assets
Each household member who owns assets
must have his or her financial institution
complete this form. Assets include, but are
not limited to:
Savings accounts
Checking accounts
IRAs, CDs or bonds
Real estate
Stocks/bonds
Recent financial statements from the
institution or bank may be submitted as an
alternative.
□ Yes, given to
financial
institution

documentation
enclosed
□ N/A
click to sign
signature
click to edit
Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY NUMBER (last 4
digits)
RECERTIFICATION PACKAGE CHECKLIST CONTINUED
Form #
Form Name
Who Must Complete this Form
Form
Completed
6
Declaration of Un-
Reimbursed Medical and
Pharmacy Expenses
You may complete this form if the Head of your
Household, spouse or co-head are:
Legally disabled
62 years of age or older
This form may be completed to deduct un-
reimbursed medical, pharmacy, or disability
expenses expected in the next 12 months. Only
the portion of the total medical expense that
exceeds 3% of the household annual income is
an allowable deduction.
This form is not complete without documentation
of these expenses.
□ Yes
□ N/A
7
Declaration of Un-
Reimbursed Disability
Expenses
If your family has an un-reimbursed expense
for attendant care (home health aid for a
disabled adult or baby-sitter for a disabled
child age 13 or older) or medical equipment
(such as a wheelchair) for a household
member who is disabled and as a result of
this expense, you or any household member
(including the disabled person) were able to
earn income from a job, you should complete
this form.
This form is not complete without documentation
of these expenses.
□ Yes
□ N/A
8
Verification of Student
Status
Each household member who is 18 years of age
or older who attends school full-time, or who is in
a job training program, must have this form
completed by the educational institution.
□ Yes
□ N/A
9
Verification of Absent
Parent
Households with children (17 years of age and
younger) who are not living with one or both of
their parents in the household must complete
this form.
□ Yes
□ N/A
10
Verification of Childcare
Expenses
This form only applies if child care expenses are
for the care of children 12 years old or younger,
and only if child care is necessary for a family
member to be employed, to further his or her
education, or to seek employment.
□ Yes
□ N/A
11
Request to Add
Household Member
Households that would like to request to add a
person to their Rental Subsidy household must
complete this form and submit the documents
requested.
□ Yes
□ N/A
12
Request to Remove a
Household Member
Households that would like to request to remove
a person to their Rental Subsidy household must
complete this form and submit the documents
requested.
□ Yes
□ N/A
click to sign
signature
click to edit
Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY NUMBER (last 4
digits)
LANGUAGE ASSISTANCE FORM
Spanish / Español
Si usted desea ayuda en algún idioma para completar este paquete, por favor llame al 917-286-4300. Un
representante HPD podrá ayudarlo a obtener ayuda. Por favor marque el casillero al final de esta declaración si
es que a usted le gustaría que registremos la preferencia de idioma marcada para referencia futura.
French / Français
-286-4300.
Un représentant du servi
de cet énoncé si vous désirez que nous notions votre préférence de langue indiquée pour référence future.
Haitian Creole / Kreyòl ayisyen
Si w ta renmen jwenn asistans pou ranpli pake sa a, tanpri rele 917-286-4300. Yon anplwaye HPD ap kapab ba
ou bon jan asistans. Tanpri tcheke kaz ki nan fen fraz sa a si w ta renmen nou endike lang ou pi pito pou
referans alavni.
Russian / Русский
            -286-4300.
  HPD        

Cantonese / 廣東話
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
 -- 


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.
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Completed 28 January 2021

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