FAMILY INFORMATION CERTIFICATION

Name	Contact Telephone Number

MAILING Address: 	(Check Here if new □)

E‐mail Address: 	

** IT IS YOUR RESPONSIBILITY TO FULLY REPORT ALL HOUSEHOLD INCOME, EXPENSES AND OCCUPANTS IN WRITING**
READ THIS FORM CAREFULLY. Full written disclosure is required. Incomplete reports will not be processed.

HAVE YOU HAD ANY CHANGES IN YOUR HOUSEHOLD SINCE YOUR LAST APPOINTMENT?
□	NO. I have had no changes since my last review.
□	YES. Date Change Happened: 	
Explain Change: 	

STATEMENT OF FAMILY COMPOSITION
LIST ALL OF PEOPLE LIVING IN YOUR HOUSEHOLD (OR WHO WILL BE LIVING WITH YOU). LIST YOURSELF FIRST.
HOUSEHOLD MEMBER NAME	RELATIONSHIP TO HEAD OF HOUSEHOLD	BIRTHDATE	AGE	LAST FOUR DIGITS OF SOCIAL SECURITY #	WORKING? (ANSWER YES OR NO)	STUDENT? (ANSWER YES OR NO)	
	MYSELF						

							

**BY SIGNING THIS FORM I/WE CERTIFY THAT ALL MINORS LISTED ON THIS FORM (OR AN ATTACHED FORM) ARE LEGALLY AND PHYSICALLY IN MY/OUR CUSTODY. **

ARE YOU: □ MARRIED	□ DIVORCED  □ SEPARATED  □ SINGLE  □ WIDOWED □ DOMESTIC PARTNERSHIP

IS THERE ANYONE LISTED ON YOUR FOODSTAMP CASE (if any) WHO IS NOT LISTED ON THIS FORM?
□	NO	□ YES ‐ NAME	 Explain Why: 	

IS THERE ANYONE WHO STAYS IN YOUR HOME ON A REGULAR BASIS WHO IS NOT LISTED ON THIS FORM?
□	NO	□ YES ‐ NAME:	
If yes, EXPLAIN WHY & HOW OFTEN: 	

HOUSEHOLD INCOME, EXPENSES AND ASSETS *
INCOME: (REPORT ALL JOBS WORKED BY ANY/ALL HOUSEHOLD MEMBERS IN THE LAST 12 MONTHS. USE THE EMPLOYMENT HISTORY REPORTING FORM IF YOU NEED ADDITIONAL SPACE TO REPORT.)
NAME OF EMPLOYED
HOUSEHOLD MEMBER:	
EMPLOYER NAME:	YOUR JOB TITLE:	
ADDRESS:	EMPLOYER TELEPHONE #:	
HOW LONG HAVE YOU BEEN EMPLOYED?
		(check one) □WKS □MOS □YRS	RATE OF PAY:
$	HOURS PER WK:	
□	Check here if, this job has ended. GIVE DATE: 		HOW OFTEN ARE YOU PAID? (check one)
□WKLY □BI –WKLY □MONTHLY	

NAME OF EMPLOYED
HOUSEHOLD MEMBER:	
EMPLOYER NAME:	YOUR JOB TITLE:	
ADDRESS:	EMPLOYER TELEPHONE #:	
HOW LONG HAVE YOU BEEN EMPLOYED?
		(check one) □WKS □MOS □YRS	RATE OF PAY:
$	HOURS PER WK:	
□	Check here if, this job has ended. GIVE DATE: 		HOW OFTEN ARE YOU PAID? (check one)
□WKLY □BI –WKLY □MONTHLY	

IS ANYONE IN YOUR HOUSEHOLD SELF‐EMPLOYED (such as lawn care, handy‐man, hair braiding, house cleaning, etc)?
□	NO	□ YES – NAME: 	 TYPE OF WORK: 	

DO YOU OR DOES ANYONE IN YOUR HOUSEHOLD RECEIVE ANY OF THE FOLLOWING?
TYPE	YES OR
NO?	IF YES, HOW
MUCH?	HOW OFTEN ARE YOU PAID?	NAME OF HH MEMBER	NAME OF CASEWORKER AT
PENDER DSS	
Work First / OAP / AND		$				
ALIMONY/MAINTENANCE		$				
FOOD STAMPS		$				
SOCIAL SECURITY/SSI/SSDI		$				
Unemployment Benefits		$				
VA Benefits		$				
Pension/retirement		$				
FINANCIAL AID		$			
GIFT OR OTHER INCOME
NOT LISTED ABOVE		$		Explain:	

DO YOU RECEIVE CHILD SUPPORT? Choose the answer that BEST describes your situation.
□	YES	□ NO – Both parents for all children are in the home.
□	NO‐there are children in my household, but I do not receive support.
□	NO‐there are NO children in my household & I am not entitled to child support (current or arrears).
□	NO – The absent parent for all children is deceased.
□	

•	DOES ANYONE NOT LISTED ON THIS FORM YOU HELP YOU PAY BILLS? □ YES □ NO
IF YES, WHO AND HOW MUCH? 	

*IF YOU ARE CLAIMING TO HAVE NO INCOME or IF THE INCOME YOU REPORT IS SO LOW THAT IT IS NOT ENOUGH TO MEET REASONABLE EXPENSES FOR YOUR FAMILY, EXPLAIN HOW YOU PAY BASIC LIVING EXPENSES.*

ASSETS:
DOES ANYONE IN YOUR HOUSEHOLD HAVE ASSETS SUCH AS CHECKING/SAVINGS ACCOUNTS, LAND, ETC.?
□	YES‐ You must disclose all accounts/assets owned by any/all household members.
□	NO, No one in my household has assets/bank accounts.

IF YOU HAVE INCOME, BUT YOU DO NOT HAVE A CHECKING/SAVINGS ACCOUNT, EXPLAIN HOW YOU RECEIVE YOUR PAY & PAY YOUR BILLS: 	

EXPENSES:

ELDERLY/DISABLED ONLY:
DO YOU HAVE OUT OF POCKET COSTS FOR MEDICAL EXPENSES?

□	YES  □ NO

IF YES, YOU MUST PROVIDE PROOF OF OUT‐OF‐POCKET COSTS INCLUDING PROOF YOU ARE PAYING THEM IN ORDER TO
RECEIVE CREDIT. A 12‐MONTH HISTORY/PRINTOUT FROM THE DOCTOR/PHARMACY/PROVIDER IS REQUIRED TO SHOW YOU ARE MAKING REGULAR PAYMENTS.

CHILDCARE:
DO YOU HAVE CHILDREN IN CHILD CARE? □ YES □ NO IF YES, COST: $
WHO PAYS THE OUT OF POCKET COST OF YOUR CHILD CARE EXPENSES?

PER (check one) □WK  □MO

DO YOU RECEIVE CHILD CARE ASSISTANCE?
□	YES ‐ PROVIDE A COPY OF YOUR PARENT FEE WORKSHEET.
□	NO ‐ GIVE NAME, ADDRESS & PHONE NUMBER OF YOUR CHILD CARE PROVIDER:

WHO PAYS UTILITIES WHERE YOU LIVE NOW? 	
Check the utilities that you are responsible for paying:  □ Electric	□ Gas/oil	□ Water □ Sewer	□ Trash

DO YOU EXPECT ANY CHANGES FOR YOUR FAMILY IN THE NEXT 12 MONTHS, INCLUDING ANY UPCOMING
CHANGES IN HOUSEHOLD INCOME? (i.e.: new baby, marriage/divorce, someone moving?)
□	NO □YES, EXPLAIN: 	

DO YOU HAVE A CAR?	□ NO	□ YES ‐ ANSWER THE FOLLOWING:
WHOSE NAME IS ON THE CAR REGISTRATION? 	
WHO PAYS FOR:	CAR INSURANCE: 		AMT: $	 PER MO GAS & REPAIRS: 	 	AMT: $	 PER MO
DO YOU HAVE A CAR PAYMENT? □ NO  □ YES – ANSWER THE FOLLOWING QUESTION:
WHO PAYS IT? 		AMT: $	 PER MO

Do you have a cell phone? □ NO □ YES – Whose name is on the bill? 	
Do you have cable or satellite TV? □ NO □ YES – Whose name is on the bill? 	
Do you have a water bill? ___________

If you have very low or no income, how do you pay for “extras” like tattoos, eating out, cigarettes, alcohol, hair color, artificial nails, etc? (If someone else pays for “extras”, please explain who and how much)

Please explain any changes in your criminal history or that of any household member since your last report (OR since you applied, if you are interviewing for eligibility). Use a separate sheet of paper, if needed.
□	No Change
□	Yes, there are have changes. EXPLAIN: 	

I CERTIFY THAT THE INFORMATION I HAVE PROVIDED IS TRUE & COMPLETE TO THE BEST OF MY KNOWLEDGE. I DECLARE UNDER PENALTY OF PERJURY, & BEING SUBJECT TO PROSECUTION UNDER THE N. C. GENERAL STATUTE 15§157‐29, THAT THE INFORMATION IS TRUE & COMPLETE.

I/WE UNDERSTAND THAT INFORMATION GIVEN TO THE HOUSING AUTHORITY MAY BE GIVEN TO THE PENDER COUNTY DEPARTMENT OF SOCIAL SERVICES. I/WE CERTIFY THAT I/WE HAVE READ AND UNDERSTAND THE ABOVE STATEMENT.

BY SIGNING THIS DISCLOSURE, I /WE HEREBY AUTHORIZE THE PENDER COUNTY HOUSING DEPARTMENT (OR IT’S AGENT), TO CONTACT & OBTAIN ANY INFORMATION REQUIRED FROM ANY OF THE INDIVIDUALS /ENTITIES LISTED ON THIS DISCLOSURE, OR FROM ANY OTHER INDIVIDUALS/ENTITIES REQUIRED TO VERIFY ELIGIBILITY.

(ALL ADULT HOUSEHOLD MEMBERS, 18 YEARS OLD OR OLDER, MUST SIGN THIS FORM)

HEAD OF HOUSEHOLD:	 DATE 	

OTHER ADULT: 		DATE	

OTHER ADULT: 	 DATE	

OTHER ADULT: 	 DATE	

Pender County Housing Department

Post Office Box 1149	Telephone: (910) 259‐1208
805 South Walker Street	FAX: (910)259‐1343 Burgaw, North Carolina 28425

CHILD SUPPORT AFFIDAVIT

Head of Household Name (Print)

Use this form to disclose all amounts/kinds of child support received. If you have more than one child but your children do not have the same absent parent, then complete a separate form for each.

Child(ren)’s Names (print)	Date of Birth	

INDICATE ANY TYPE OF SUPPORT RECEIVED FOR THE CHILDREN LISTED ABOVE:
□	COURT ORDERED SUPPORT: $	 PER 	(month/week/day)
□	PAYMENTS ARE THROUGH NC CHILD SUPPORT ENFORCEMENT (A 12‐month history is required)
□	PAYMENTS COME FROM ANOTHER STATE/COUNTY, EXPLAIN WHERE/HOW PAID:

□	ABSENT PARENT PAYS ME DIRECTLY (NO COURT ORDER): $	 PER 	.
(A notarized affidavit is required.)	(month/week/day)

□	ABSENT PARENT PAYS EXPENSES AND/OR BUYS GOODS. EXPLAIN: 	
	 (A notarized affidavit is required)

□	ABSENT PARENT DOES NOT PAY: IT IS COURT ORDERED FOR 	
(A statement from Child Support showing that you do not have an open case is required.)

□	ABSENT PARENT DOES NOT PAY: IT IS NOT COURT ORDERED. ABSENT PARENT DOES NOT HELP WITH
EXPENSES. (A statement from Child Support showing that you do not have an open case is required.)

□	ABSENT PARENT IS INCARCERATED (JAIL/PRISON). DATE OF INCARCERATION: 	
□	I DID NOT PURSUE CHILD SUPPORT BECAUSE: 	

By my signature below, I certify that the information above is true and complete. I understand it is my responsibility to notify PCHD of any changes to the status of child support. WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful, false statements of misrepresentation to any Department or Agency of the U.S. as to any matter within its jurisdiction.

Signature of Applicant/Resident	Date
	 www.pendercountync.gov	
This institution is an equal opportunity provider and employer.

PENDER COUNTY HOUSING DEPT. ASSET CERTIFICATION

	Complete one form per household member who has separate assets, including children.	

Head of Household Name		
Owner of the account (if not the head of household)		

SECTION BELOW TO BE COMPLETED BY APPLICANT/RESIDENT

Choose One:
Within the past 2 years, I/We have sold or given away assets (including cash, real estate, etc.) for more than $1,000 below the fair market value (FMV). The amounts are included below & are equal to: $ 	, the difference between FMV and the amount received, for each asset on which this occurred.

I/We have NOT sold or given away any assets (including cash, real estate, etc.) for less than FMV during the past 2 years.

Assets include: Some Funds (e.g. Retirement, Pension, Trusts) may not be (fully) accessible to you. Include only those amounts which are accessible. ATTACH A COPY OF YOUR MOST RECENT STATEMENT FOR ALL BANK ACCOUNTS, RETIREMENT ACCOUNTS, PENSION ACCOUNTS, ETC.
*Cash Value is defined as market value minus the cost of converting the asset to cash, such as broker fees, settlement costs, outstanding loans, early withdrawal penalties, etc. **Personal property held as an investment may include, but is not limited to, gem or coin collections, antique cars, etc. DO NOT include necessary personal property.

Type	(A)
Cash Value	(B)
Int.
Rate	
Source/ Name of Institution/ Agent		Type	(A)
Cash Value	(B)
Int.
Rate	Source/Name of Institution/ Agent	
Savings Account					Cash on Hand				
Checking Acct					Safety Deposit Box				
CDs/Stocks/Bonds					Lump Sum
Receipts				
IRA Acct/401K					Money Market				
Keogh Acct					Trust Fund				
Life Ins Policies (Whole Life Only)					Capital Investments				
Real Estate/Land/ Land Contracts/
Land Leases			Address of real estate/land/leasehold:	
Other Retirement/ Pension Funds
Not named herein:					Other (List) including personal
property held for investment:				

Initials of HoH

I/We DO NOT have any assets at this time. (complete by Head of Household if NO ONE in the family has assets)

Under penalty and perjury, I/we certify that the information presented in this certification is true and accurate to the best of my/our knowledge. The undersigned further understand(s) that providing false information herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination of a Lease Agreement.

Applicant/Resident Signature		Date		Applicant/Resident Signature		Date	
Applicant/Resident Signature		Date		Applicant/Resident Signature		Date	

Pender County Housing Department

Post Office Box 1149	Telephone: (910) 259‐1208
805 South Walker Street	FAX: (910)259‐1343 Burgaw, North Carolina 28425

Consent to Release Information

Head of Household Name	Address

To Whom It May Concern:

My/our family participates in an affordable housing program in which verification of income, assets and expenses is required in order to determine eligibility for program participation and for participation to be continued annually. By my/our signature(s) below, I/we authorize all persons/companies/agencies, in the categories below to release, without liability, requested information including, but not limited to, the following:

•	Income from: employment; public and private pensions; retirement accounts; Veterans Administration; Social Security; gifts; child support; alimony/maintenance; OAP; TANF; and other types of income or benefits.
•	Asset information: average balances of checking and savings accounts; cash value of retirement accounts; cash value of stocks/bonds; cash value of collectibles; value and terms of trusts; or other items that may be considered assets.
•	Out‐of‐pocket costs for expenses including medical, dental and child care.
•	Other information relevant to the household’s participation such as residency history; verification of addresses; verification of school enrollment; verification of non‐cash benefits; etc.

I/we give our consent to release information regarding income, assets and expenses for all members of the household. I/We agree that a photocopy of this authorization may be used for the purposes stated above. I/We expressly release the provider and the procurer of information from any liability in the use, procurement or furnishing of information and understand that the information may be provided to various local, state and/or federal government agencies including, without limitation, law enforcement agencies. I/We understand that this release is good for 15 months from the date of signature.

	Signature of Head of Household				Last 4 digits of SSN		Date	
	Signature of Adult HH Member				Last 4 digits of SSN		Date	
	Signature of Adult HH Member				Last 4 digits of SSN		Date	
	Signature of Adult HH Member				Last 4 digits of SSN		Date	

www.pendercountync.gov
This institution is an equal opportunity provider and employer.

Authorization for the Release of Information/ Privacy Act Notice

U.S. Department of Housing and Urban Development
Office of Public and Indian Housing

to the U.S. Department of Housing and Urban Development (HUD)	OMB CONTROL NUMBER: 2501-0014
and the Housing Agency/Authority (HA)	exp. 1/31/2014

PHA requesting release of information; (Cross out space if none)
(Full address, name of contact person, and date)	IHA requesting release of information: (Cross out space if none)
(Full address, name of contact person, and date)	
Pender County Housing Dept. P O Box 1149
Burgaw, NC 28425		
910.259.1208
910.259.1343 - FAX		

Authority: Section 904 of the Stewart B. McKinney Homeless Assistance Amendments Act of 1988, as amended by Section 903 of the Housing and Community Development Act of 1992 and Section 3003 of the Omnibus Budget Reconciliation Act of 1993. This law is found at 42 U.S.C. 3544.
This law requires that you sign a consent form authorizing: (1) HUD and the Housing Agency/Authority (HA) to request verifi- cation of salary and wages from current or previous employers; (2) HUD and the HA to request wage and unemployment compensa- tion claim information from the state agency responsible for keeping that information; (3) HUD to request certain tax return information from the U.S. Social Security Administration and the
U.S. Internal Revenue Service. The law also requires independent verification of income information. Therefore, HUD or the HA may request information from financial institutions to verify your eligibility and level of benefits.
Purpose: In signing this consent form, you are authorizing HUD and the above-named HA to request income information from the sources listed on the form. HUD and the HA need this information to verify your household’s income, in order to ensure that you are eligible for assisted housing benefits and that these benefits are set at the correct level. HUD and the HA may participate in computer matching programs with these sources in order to verify your eligibility and level of benefits.
Uses of Information to be Obtained: HUD is required to protect the income information it obtains in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. HUD may disclose information (other than tax return information) for certain routine uses, such as to other government agencies for law enforcement purposes, to Federal agencies for employment suitability purposes and to HAs for the purpose of determining housing assistance. The HA is also required to protect the income information it obtains in accordance with any applicable State privacy law. HUD and HA employees may be subject to penalties for unauthorized disclosures or im- proper uses of the income information that is obtained based on the consent form. Private owners may not request or receive information authorized by this form.
Who Must Sign the Consent Form: Each member of your household who is 18 years of age or older must sign the consent form. Additional signatures must be obtained from new adult members joining the household or whenever members of the household become 18 years of age.

Persons who apply for or receive assistance under the following programs are required to sign this consent form:
PHA-owned rental public housing Turnkey III Homeownership Opportunities Mutual Help Homeownership Opportunity Section 23 and 19(c) leased housing Section 23 Housing Assistance Payments HA-owned rental Indian housing
Section 8 Rental Certificate Section 8 Rental Voucher
Section 8 Moderate Rehabilitation
Failure to Sign Consent Form: Your failure to sign the consent form may result in the denial of eligibility or termination of assisted housing benefits, or both. Denial of eligibility or termi- nation of benefits is subject to the HA’s grievance procedures and Section 8 informal hearing procedures.
Sources of Information To Be Obtained
State Wage Information Collection Agencies. (This consent is limited to wages and unemployment compensation I have re- ceived during period(s) within the last 5 years when I have received assisted housing benefits.)
U.S. Social Security Administration (HUD only) (This consent is limited to the wage and self employment information and pay- ments of retirement income as referenced at Section 6103(l)(7)(A) of the Internal Revenue Code.)
U.S. Internal Revenue Service (HUD only) (This consent is limited to unearned income [i.e., interest and dividends].)
Information may also be obtained directly from: (a) current and former employers concerning salary and wages and (b) financial institutions concerning unearned income (i.e., interest and divi- dends). I understand that income information obtained from these sources will be used to verify information that I provide in determining eligibility for assisted housing programs and the level of benefits. Therefore, this consent form only authorizes release directly from employers and financial institutions of information regarding any period(s) within the last 5 years when I have received assisted housing benefits.

Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form for the purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs that receive income information under this consent form cannot use it to deny, reduce or terminate assistance without first independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In addition, I must be given an opportunity to contest those determinations.
This consent form expires 15 months after signed.

Signatures:

Head of Household	Date

Social Security Number (if any) of Head of Household	Other Family Member over age 18	Date

Spouse	Date	Other Family Member over age 18	Date

Other Family Member over age 18	Date	Other Family Member over age 18	Date

Other Family Member over age 18	Date	Other Family Member over age 18	Date

Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair Housing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and participants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay toward rent and utilities. Other Uses: HUD uses your 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 you provide. This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or 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 HA, including all Social Security Numbers you, and all other household members age six years and older, have and use. Giving the Social Security Numbers of all household members six 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.

Penalties for Misusing this Consent:

HUD, the HA and any owner (or any employee of HUD, the HA 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 the form HUD 9886 is restricted to the purposes cited on the form HUD 9886. 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 of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use.

Pender County Housing Department
FAMILY OBLIGATIONS and TERMINATION DISCLOSURE

FAMILIES WHO DO NOT COMPLY WITH THEIR OBLIGATIONS UNDER THE HOUSING ASSISTANCE PROGRAMS RUN THE RISK OF TERMINATION. IN SOME INSTANCES, FAMILIES RISK CRIMINAL PROSECUTION. PLEASE PROTECT YOURSELF AND YOUR FAMILY BY ENSURING THAT EVERYONE IN YOUR HOUSEHOLD ABIDES BY THE PROGRAM GUIDELINES.

FAMILY OBLIGATIONS:

1.	Families are required to report all changes in household income and/or composition in writing within 10 days. Please schedule an appointment to report the change. A phone call is not considered a report of a change.

2.	The family must provide any/all information, certifications and consent agreements that HUD, USDA or PCHD determines is necessary in the administration of the program.

3.	The family must provide any information requested by HUD, USDA or PCHD for use in regularly scheduled examinations or interim re‐examinations to determine continued eligibility.

4.	Any and all information provided by the family must be true and complete. All adult household members must sign forms certifying that the information supplied is accurate.

5.	Housing Quality Standards (HQS) ‐ The family is required to maintain rental units to HQS standards including good housekeeping. Breaches in HQS are a violation of family obligations and may include but are not limited to:
•	Resident–supplied utilities
•	Appliances furnished by the Resident
•	Resident damages to the unit or premises beyond normal wear and tear
•	Failure to cooperate with scheduled inspections of unit

6.	Families must comply with the terms of the lease agreement. Serious or repeated lease violations are violations of the voucher program guidelines.

7.	Families must notify PCHD & the landlord in writing at least 30 days before moving out of a unit or terminating a lease.

8.	Voucher Program ‐ The family must give PCHD a copy of any eviction notice within 48 hours of receipt.

9.	Families must use the assisted unit for a residence and it must be the only residence for the family.
•	With written approval from the landlord, household members may engage in legal profit‐making activities if they do not interfere with the primary use of the unit as a residence.
•	The family must not sublease or let the unit and must not assign the lease or transfer the unit.

10.	All individuals living in a unit must be approved by PCHD. It is the family’s responsibility to report changes including, but not limited to:
•	The birth, adoption or court awarded custody of children.
•	Prior approval from PCHD is required to add any adult (18 yrs or older) to the household.
•	If any family member moves out.

11.		If a family will be absent from a unit for more than 10 days, PCHD may verify the reason for the absence. Families are responsible for notifying PCHD in writing if an absence will be 30 days or more.

Fam Ob Term Discl 02.2014 v.2

12.	Families must not commit fraud, bribery or any other corrupt or criminal acts in connection with the program.

13.	Family members and/or their guests may not engage in criminal activity, drug‐related criminal activity or any violent criminal activity.

14.	The household may not receive rental assistance from the Housing Choice Voucher Program or USDA’s Rental Assistance program while receiving another type of housing assistance either for the same or for a different unit.

15.	Families, including Heads, co‐Heads, spouses or children, are not permitted to swear at, threaten or otherwise abuse Housing Authority staff or the staff/contractors working at Seven Oaks Apartments or Country Court Apartments.

GROUNDS FOR DENIAL OR TERMINATION OF ASSISTANCE:
Applicants may be denied assistance & participants may be terminated from the voucher program:

•	For violations of any family obligation, including compliance with the terms of the lease.
•	If any member of the family has ever been evicted from subsidized housing.
•	For failure of any household member to comply with program requirements.
•	If any household member or guest commits criminal activity, drug‐related criminal activity or violent criminal activity.
•	If any household member commits fraud, bribery or any corrupt or criminal act in connection with any federally assisted housing program.
•	If the family currently owes money to PCHD or another Housing Authority.
•	If the family has not paid/reimbursed an owner for rent, damages or other amounts due under the lease.
•	If the family violates an agreement to pay amounts owed to PCHD as a result of a lease or program violation.
•	If the family has engaged in or threatened abusive or violent behavior towards PCHD personnel.
•	If the family fails to submit required evidence of citizenship or eligible immigration status.
•	If the family does not report changes in household income or composition within 10 days.
•	PCHD must deny or terminate assistance if any family member fails to sign and submit consent forms for obtaining information.

**Families who do not report changes timely will be required to reimburse PCHD for any overpayment of assistance. PCHD requires that the balance be paid in full unless repayment arrangements are made. PCHD requires a down‐ payment of 30% of the amount owed in order to accept a repayment arrangement.**

By signing below, I/we acknowledge receipt of this disclosure. The information has been reviewed and I/we were given the opportunity to ask questions. My/Our signature(s) below acknowledges my/our understanding of my/our responsibilities.

Signature	Date

Signature	Date

Signature	Date

RACE AND ETHNIC DATA REPORTING FORM
Pender County Housing Authority 

                   Tenant Name: ________________________________________               Date: _______________________

RACIAL/ETHNICAL CATEGORIES	RELATIONSHIP TO HEAD OF HOUSEHOLD	RACE/ETHNICITY	
CAUCASION	                         
MYSELF		
AFRICAN AMERICAN			
ASIAN			
AMERICAN INDIAN			
HISPANIC			
NATIVE HAWAIIAN			
OTHER			

OMB 2535-0113 - All HUD program offices use this form when collecting information concerning the race and ethnicity of the populations intended to benefit from HUD funding as required by Title IV of the Civil Rights Act of 1964.

I certify that all information given above is accurate to the best of my knowledge. 

Tenant Name (print): ___________________________________________________

Tenant Name (sign): ___________________________________________________

                                                                               Date: __________________