Fill - Free fillable SELF-CERTIFICATION / STATEMENT OF FACT (Housing Authority of the County of Santa Cruz) PDF form

050340 12/12/05 JP

2160 41

Avenue, Capitola, CA 95010 Telephone: (831) 454-9455, Hollister: (831) 637-0487

Fax: (831) 469-3712, TDD (831) 475-1146

www.hacosantacruz.org

SELF-CERTIFICATION / STATEMENT OF FACT

Head of Household Name:

Tenant ID:

Address:

Telephone:

By signing this form I, _______________________________________ certify that: _________________________________

_____________________________________________________________________________________________________

I further acknowledge and understand that this Self-Certification is true, correct, and complete and will be relied upon for

purposes of determining my assistance for the Section 8 Housing Choice Voucher Program or Low Income Public Housing.

Any misstatement or false statement may result in denial / loss of assistance. In addition, I understand that any

misrepresentation in my statements may be considered to be fraud and I may be required to repay all assistance overpaid on

behalf of my family.

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 Name Signature Date

Print Head of Household Name Signature Date

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SELF-CERTIFICATION STATEMENT OF FACT (Housing Authority of the County of Santa Cruz)

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