Eden, Inc. Housing Application Form (Page 4 of 7) in pdf

Kathryn Kazol, Executive Director

EDEN-HUD SUBSIDIZED HOUSING AFFIDAVIT

STATE OF OHIO, COUNTY OF CUYAHOGA c/o EDEN, Inc./Third Project Apts.

To:

From:

RETURN THIS VERIFICATION TO THE PERSON LISTED ABOVE

BACKGROUND AND RECORD RELEASE STATEMENT:

Subject:

Name

Address

City, State & Zip

D.O.B.

SSN:

This person has applied for housing assistance under a program of the U.S. Department of Housing and Urban

Development (HUD). HUD requires the housing owner to verify all information that included in determining this

person’s eligibility or level of benefits.

Information being requested: A criminal background check is being completed via First Advantage SafeRent

which includes a statewide search and multi state sex offender search.

Completed by:

Date:

⁭

yes

Cleared:

Do not attach results. They are filed separately.

RELEASE: I hereby authorize the release of the requested information. Due to the eligibility guidelines established by

HUD regarding criminal activity I further understand that they will be verifying information up to 5 years old.

Signature

Date

Note to Applicant/Tenant: You do not have to sign this form if either the requesting organization or the organization

supplying the information is left blank.

PENALTIES FOR MISUSING THIS CONSENT:

Title 18, Section 1001 of the U.S. Code states 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 and any owner (or any employee of HUD 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 willingly

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 of information may bring civil action for

damages and seek other relief, as may be appropriate, against the officer or employee of HUD 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 208 (a)

(6), (7) and (8). Violations of these provisions are cited as violations of 42 USC 408 (a) (6), (7) and (8).

A H o u s i n g R e s o u r c e a n d D e v e l o p m e n t A g e n c y

7812 Madison Avenue, Cleveland, OH 44102 (216) 961-9690 FAX (216) 651-4066

Shelter Plus Care FAX (216) 651-6692

TDD/TTY: 1-800-545-1833, ext. 873

P:forms3

party verificationscriminal background 2009

Revised effective 7/1/09

Eden, Inc. Housing Application Form Page 4

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