Number of adults (over age 18):
Number of children:
Other Household Member
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.
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.
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)
Giving True and Complete information.
I/we certify that all the information given on household, composition, income and family assets is accurate and complete to the best of my/our knowledge. I/we have reviewed this Application Form and certify that the information shown is true anmd correct.
Reporting on Prior Housing Assistance
I/we certify that I/we have disclosed where I/we have received any previous Federal housing assistance and whether or not any money is owed. I/we certify that for the previous assistance , I/we did not commit any fraud, or knowingly misrepresent any information, or vacate the unit in violation of the lease.
Criminal and Administrative Actions for False Information
I/we understand that knowingly supplying false, incomplete or inaccurate information is punishable under Federal and State criminal law. I/we understand that knowingly supplying false, incomplete or inaccurate information is grounds for denial of this application or termination of housing assistance or termination of tenancy.
Determination of Eligibility
I/we understand that this is only my/our “initial application” and that I/we shall be required to update at a later time, so that the Housing Authority can determine my/our eligibility for the housing assistance program.
Release of Information
I/we do hereby consent and authorize the release of any and all information to the Concord Housing Authority from the sources listed on this application for the purpose of verifying my/our eligibility and benefit level. I/we do hereby release, remise and forever discharge from any action whatsoever, in law and equity, all Concord Housing Authority employees and agents in connection to the processing, investigation or credit checking of this application and will hold harmless from any suit or reprisal whatsoever.
By signing below, I/we attest that all the information contained in this application is true and accurate to the best of my/our knowledge. I/we have read and understand all sections of this application.
Please type the names of all adult household members
Concord Housing Authority does not discriminate against any person because of color, religion, handicap, familial status, sexual orientation, sex, race, marital status, age or national origin.
Applicant must notify CH+R of any address and/or telephone changes immediately. Failure to do so may result in termination from the wait list.
Completed applications will be added to the wait list on the date they are received. Incomplete applications will not be processed.