Sample Self-Certification/declaration Of Income - Department Of Housing And Urban Development
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1SAMPLE SELF-CERTIFICATION/DECLARATION OF INCOME
(Parents Program Eligibility for Students in the Section 8 Housing Program)
I/we the parent(s) of ________________________________________, certify the following:
I am currently receiving housing assistance from the Department of Housing and Urban Development
□
□
Yes
No
If “Yes”, skip to address information below. If “No”, proceed to next question.
My/our current annual gross income is $____________________
This amount includes all income received by the parent(s) from employment, income from assets, federal
state and local benefits and any other income.
There are a total of _______________ people who are living with me/us as part of my/our household.
(Do not count the student applicant as part of the household.)
My/Our Address is:
______________________________________________________________
______________________________________________________________
______________________________________________________________
Apartment or Community Name: ________________________________________________________
□
□
The above information has been provided for
one parent
both parents. (Please check the appropriate box.)
or
I do not have contact with or am unable to provide contact information for my parent(s) and certify that that
□
I am not receiving, directly or indirectly, any financial assistance from them.
PENALTIES FOR MISUSING THIS FORM
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, the PHA and any owner (or any employee of HUD, the PHA 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, the PHA 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.
Parent Signature:____________________________ Date: _____________________
Print Name: _________________________________
Parent Signature: _____________________________ Date: ______________________
Print Name: _________________________________
Student Signature for Self-Certification (if applicable):______________________________________
Sample Parent Self-Certification Form
Rev. 6/19/15
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