Exp. (07/31/2012)
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.
Applicant Name:
Mailing Address:
Telephone No: Cell Phone No:
Name of Additional Contact Person or Organization:
Telephone No: Cell Phone No:
E-Mail Address (if applicable):
Relationship to Applicant:
Reason for Contact: (Check all that apply)
E
Unable to contact you
Termination of rental assistance
Eviction from unit (LIPH only)
Late payment of rent (LIPH only)
Assist with Recertification Process
Change in lease terms (LIPH only)
Change in house rules (LIPH only)
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.
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.
Privacy 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 (05/09)
