PREVIOUS HOUSEHOLD MEMBER CERTIFICATION

Date:

Apartment Number:

Address:

Name of Person Remaining in Apartment:

Absent Family Member:

Absent Family Member Move-Out Date:

Absent Family Member Current Address:

City: State: Zip Code: Please remove my/his/her name from the lease and/or recertification. Attached are the required documents showing my/his/her new address. Office Use Only

Manager: Indicate items attached by checking the applicable boxes below:

Lease for new address

Telephone bill for new address

Utility bill for new address

Witnessed statement from landlord (owner) or management company (letterhead accepted) indicating residency

Other: (these items must be of legal acceptance) please specify:

______

______

Printed Name: Telephone Number:

Signature: Date:

SIGNATURE MUST BE NOTARIZED OR WITNESSED BELOW Subscribed and sworn to before me this ______day d

d Witness Printed Name: e

e of ______, ______. s z i s r e a t n

Signature of Notary: t Witness signature: i o N W

f f I My Commission Expires: I Date Witnessed:

PLEASE READ THE STATEMENTS BELOW CAREFULLY BEFORE SIGNING THIS VERIFICATION FORM

PENALTIES FOR MISUSING THIS CONSENT: Title 18, Section 1001 of the U.S. Code state that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD, the PHA, Rural Housing Service (RHS) and any owner (or any employee of HUD, the PHA, RHS or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure or information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the PHA, RHS or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 42 U.S.C. 208 (f) (g) and (h). Violation of these provisions are cited as violations of 42 U.S.C. 408 f, g and h.

WARNING: Section 1001 of Title 18, United State code provides: “Whoever, in any matter within any jurisdiction of any department or agency of the United States knowingly or willfully falsifies, conceals or covers up… a material fact, or makes any false, fictitious or fraudulent statements or representation, or makes any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than 5 years or both.”

NOTE: This Apartment Community does not discriminate on the basis of handicapped status in the admission or access to, or treatment of employment in, its federally assisted programs and activities.

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