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    Certification

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    Ms. Kea

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    © All Rights Reserved
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    Certification

    Uploaded by

    Ms. Kea
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    Original Title

    Certification (3)

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    Certification

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    Certification

    Section 8 Tenant-Based Assistance


    Rental Voucher Program
    Tenant ID
    WARNING: BY SIGNING THIS FORM, YOU ARE INDICATING THAT YOU HAVE READ AND ARE AGREEING
    WITH ITS CONTENTS

    UNIT ADDRESS 1015 Sadie Street ANNUAL INCOME


    FORNEY, TX 75126 GROSS 42,204
    ADJUSTED 39,404
    CONTRACT RENT 2,150
    OCCUPANTS JAZMINE M. KEA TENANT SHARE 670
    BASH J. COPELAND IV SECTION 8 SHARE 1,480
    JANIYA M. KEA
    UTILITY ALLOWANCE 315
    JANELLE M. COBBIN
    UTILITY REIMBURSEMENT 0
    DAMARI L. KINNEY
    VANEOUS R. WRIGHT III
    EFFECTIVE DATE 06/01/2022

    FEDERAL PRIVACY ACT NOTICE


    PURPOSE: Family income and other information is being collected by the Department of Housing and Urban Development (HUD) to
    determine an applicant's eligibility, the recommended unit size, and the amount the family must pay toward rent and utilities.

    USE: HUD uses 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 furnished. HUD or a public housing agency/Indian
    housing authority may conduct a computer match to verify the information you provided. This information may be released to appro-
    priate Federal, State, and local agencies, when relevant, and to civil, criminal and regulatory investigators and prosecutors. However,
    the information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law.

    PENALTY: You must provide all of the information requested by the public housing agency/Indian housing authority, including all social
    security numbers you, and all other household members age six (6) years and older, have and use. Giving the social security numbers
    of all household members 6 years of age and older 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 rejection of your eligibility approval.

    AUTHORITY FOR INFORMATION COLLECTION: The following laws authorize the collection of this information by HUD or the public
    housing agency/Indian housing authority: the U.S. Housing Act of 1937 (42 U.S.C., 1437 et seq.), Title VI of the Civil Rights Acts of
    1964, and Title VIII of the Civil Rights Act of 1968. The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires
    applicants and residents to submit the social security numbers of all household members at least six (6) years old.

    TENANT(S)' CERTIFICATION

    Under the penalty of perjury, I/We certify that the information provided is true and complete to the best of my/our knowledge
    and belief. I/We understand that we can be fined up to $10,000, or imprisoned up to five years, or lose the subsidy HUD pays
    and have my/our rent increased, if I/we furnish false or incomplete information.

    AGENT CERTIFICATION
    I certify that this tenant's eligibility, rent and assistance payment have been computed in accordance with HUD's regulations and
    administrative procedures and that all required verifications were obtained.

    #HOHTenant #HOHTenantTimestamp

    JAZMINE M. KEA Head of Household Date


    #HOHTenantUser

    #CoHead #CoHeadTimestamp #Agency #AgencyTimestamp

    Spouse/Co-Head Date TANYMA ALLEN, HOUSING OCCUPANCY Date


    #CoHeadUser TECHNICIAN
    #AgencyUser
    Document ID: 12733181885

    ©2022, MRI Software LLC - All Rights Reserved. TA 04/28/2022 Page 1

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