New Resident Application (NY) - CRM Rental Management

Interested in becoming a part of the CRM community?

Fill out the online application below.

Please note that there may be further forms required. We will contact you regarding this process. Thank you for your application.

"*" indicates required fields

Step 1 of 12

Select the property you are applying to*

If you need a reasonable accommodation due to disability we can provide an alternative method for your application process upon your request. Please answer all questions and include all the information requested. If a question does not pertain to you, please indicate N/A in the answer space. FAILURE TO DO SO WILL RESULT IN THE APPLICATION BEING CONSIDERED INCOMPLETE AND THEREFORE WILL NOT BE PROCESSED. Make certain you carefully read and understand all items before you submit this application. All information is confidential. Pets are only allowed in our senior citizen properties or for persons with disabilities who require a service / companion animal. The occupancy of a unit is subject to possession of the unit being delivered by the present occupant. It is understood that this application and each prospective occupant is subject to approval and acceptance. Approval is based on, but not limited to, applicants demonstrating the ability to pay required rent and other criteria depending on the property program requirements. When approved and accepted the applicant agrees to execute a lease before possession is given and to pay the first month’s rent plus the required security deposit.

PLEASE NOTE: ALL MEMBERS OF THE HOUSEHOLD 18 YEARS AND OLDER ARE REQUIRED TO COMPLETE AN APPLICATION FOR RESIDENCY. All questions must be answered. Failure to answer all questions will result in delay in processing.

Affordable Housing Program

You have applied to live in an apartment governed by an Affordable Housing program. This program requires management to certify all income, assets, and household composition as part of determining your household's eligibility. Management must determine this prior to granting your eligibility and if such eligibility is granted, each year you remain in the unit. This check box gives Management/third party authorization to assist you in completing the forms necessary for your initial certification or annual certification.

I agree

Please complete the following to help us identify which forms of advertisement or outreach we are using in accordance with our AFHMP that is working to reach our targeted areas.

How did you hear about our community?*

Apartments.com

Facebook

Google

Instagram

Print Ads/Flyers/Banners

Radio

Resident Referral

Word of Mouth

Other

Other, Please Explain:*

Applicant Information

Do you currently have a traveling voucher?*

Yes

What agency is it from?*

Name*

First Name Last Name

Size unit applying for*

Studio

One Bedroom

Two Bedroom

Three Bedroom

Four Bedroom

Sex*

Male

Female

Decline to Disclose

Status of Applicant*

Head

Co-Head

Other Adult

Social Security Number/Tax ID Number*

Date of Birth*

Month

Day

Year

Phone*

Email*

Marital Status*

Single (never married)

Widowed

Married

Divorced

Separated

Other

Spouse's Name (if applicable)

First Name Last Name

Maiden or other name (if applicable)

First Name Last Name

Driver's License Number

State of Issue

Homeless?*

Yes

Current Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Move in*

Month

Day

Year

Residency Status*

Live with Family

Rent

Own

Other

Monthly payment or rent*

How long have you resided at your current address?*

Name of Landlord*

First Name Last Name

Landlord Address*

Street Address Address Line 2 City State ZIP Code

Lease Agreement

Yes

Lease Expiration Date*

Month

Day

Year

Status*

Renting

Sold

Foreclosure

Other

Reason for Moving*

List all states anyone in the Household has lived in (please include NY)*

YOU MUST SELECT A PROPERTY AT THE TOP OF THIS FORM BEFORE CONTINUING TO THE NEXT PAGE

Household Composition

Head of Household

Name*

First Name Last Name

Relationship to Head of Household*

Date of Birth*

Month

Day

Year

Social Security Number*

Gender*

Male

Female

Decline to Disclose

Race*

This information is voluntary and is for statistical purposes and does not affect eligibility.

White

Black/African American

American Indian/Alaskan Native

Asian

Native Hawaiian/Other Pacific Islander

Refuse to Respond

Other

Ethnicity*

This information is voluntary and is for statistical purposes and does not affect eligibility.

Hispanic or Latino

Not Hispanic or Latino

Refuse to Respond

Add a second household member?*

Yes

Second Household Member

Name*

First Name Last Name

Relationship to Head of Household*

Date of Birth*

Month

Day

Year

Social Security Number*

Gender*

Male

Female

Decline to Disclose

Race*

This information is voluntary and is for statistical purposes and does not affect eligibility.

White

Black/African American

American Indian/Alaskan Native

Asian

Native Hawaiian/Other Pacific Islander

Refuse to Respond

Other

Ethnicity*

This information is voluntary and is for statistical purposes and does not affect eligibility.

Hispanic or Latino

Not Hispanic or Latino

Refuse to Respond

Add a third household member?*

Yes

Third Household Member

Name*

First Name Last Name

Relationship to Head of Household*

Date of Birth*

Month

Day

Year

Social Security Number*

Gender*

Male

Female

Decline to Disclose

Race*

This information is voluntary and is for statistical purposes and does not affect eligibility.

White

Black/African American

American Indian/Alaskan Native

Asian

Native Hawaiian/Other Pacific Islander

Refuse to Respond

Other

Ethnicity*

This information is voluntary and is for statistical purposes and does not affect eligibility.

Hispanic or Latino

Not Hispanic or Latino

Refuse to Respond

Add a fourth household member?*

Yes

Fourth Household Member

Name*

First Name Last Name

Relationship to Head of Household*

Date of Birth*

Month

Day

Year

Social Security Number*

Gender*

Male

Female

Decline to Disclose

Race*

This information is voluntary and is for statistical purposes and does not affect eligibility.

White

Black/African American

American Indian/Alaskan Native

Asian

Native Hawaiian/Other Pacific Islander

Refuse to Respond

Other

Ethnicity*

This information is voluntary and is for statistical purposes and does not affect eligibility.

Hispanic or Latino

Not Hispanic or Latino

Refuse to Respond

Add a fifth household member?*

Yes

Fifth Household Member

Name*

First Name Last Name

Relationship to Head of Household*

Date of Birth*

Month

Day

Year

Social Security Number*

Gender*

Male

Female

Decline to Disclose

Race*

This information is voluntary and is for statistical purposes and does not affect eligibility.

White

Black/African American

American Indian/Alaskan Native

Asian

Native Hawaiian/Other Pacific Islander

Refuse to Respond

Other

Ethnicity*

This information is voluntary and is for statistical purposes and does not affect eligibility.

Hispanic or Latino

Not Hispanic or Latino

Refuse to Respond

Add a sixth household member?*

Yes

Sixth Household Member

Name*

First Name Last Name

Relationship to Head of Household*

Date of Birth*

Month

Day

Year

Social Security Number*

Gender*

Male

Female

Decline to Disclose

Race*

This information is voluntary and is for statistical purposes and does not affect eligibility.

White

Black/African American

American Indian/Alaskan Native

Asian

Native Hawaiian/Other Pacific Islander

Refuse to Respond

Other

Ethnicity*

This information is voluntary and is for statistical purposes and does not affect eligibility.

Hispanic or Latino

Not Hispanic or Latino

Refuse to Respond

Add a seventh household member?*

Yes

Seventh Household Member

Name*

First Name Last Name

Relationship to Head of Household*

Date of Birth*

Month

Day

Year

Social Security Number*

Gender*

Male

Female

Decline to Disclose

Race*

This information is voluntary and is for statistical purposes and does not affect eligibility.

White

Black/African American

American Indian/Alaskan Native

Asian

Native Hawaiian/Other Pacific Islander

Refuse to Respond

Other

Ethnicity*

This information is voluntary and is for statistical purposes and does not affect eligibility.

Hispanic or Latino

Not Hispanic or Latino

Refuse to Respond

Add a eighth household member?*

Yes

Eighth Household Member

Name*

First Name Last Name

Relationship to Head of Household*

Date of Birth*

Month

Day

Year

Social Security Number*

Gender*

Male

Female

Decline to Disclose

Race*

This information is voluntary and is for statistical purposes and does not affect eligibility.

White

Black/African American

American Indian/Alaskan Native

Asian

Native Hawaiian/Other Pacific Islander

Refuse to Respond

Other

Ethnicity*

This information is voluntary and is for statistical purposes and does not affect eligibility.

Hispanic or Latino

Not Hispanic or Latino

Refuse to Respond

Do you have full custody of all children noted above?*

Yes

Partial

Absent Parent Name

Phone

Address

Street Address Address Line 2 City State ZIP Code

Student Status (LIHTC/RD)

Will ALL of the persons in the household be or have been full time students during five calendar months of this calendar year, or the upcoming calendar year at an educational institution with regular faculty and students?*

Yes

Will any household members become full time students in the next 12 months?*

Yes

Please explain*

Income Information

ALL INCOME MUST BE REPORTED

Annual income is the gross amount of income to be received by all members of the household to be in residence during 12 months following the effective date of your move-in or any subsequent rent calculations.

Household Name*

First Name Last Name

Source of Income*

Source of Income Address*

Street Address Address Line 2 City State ZIP Code

Gross Amount*

Frequency*

Weekly

Monthly

Add a second source of income?*

Yes

Second Source of Income

Household Name*

First Name Last Name

Source of Income*

Source of Income Address*

Street Address Address Line 2 City State ZIP Code

Gross Amount*

Frequency*

Weekly

Monthly

Add a third source of income?*

Yes

Third Source of Income

Household Name*

First Name Last Name

Source of Income*

Source of Income Address*

Street Address Address Line 2 City State ZIP Code

Gross Amount*

Frequency*

Weekly

Monthly

Child Support

Are you legally entitled to receive court ordered or non-court ordered support?*

Yes

What is the amount you are entitled to receive?*

Have you been receiving the amount above in child support?*

Yes

If no, what is the amount you receive?*

Taxes

Has any household member filed income taxes for the last year?*

Yes

If yes, what was the filing status listed on the income tax return?*

Single

Married Filing Jointly

Married Filing Separately

Head of Household

Qualifying Widow(er) with dependent

Assets

List ALL assets and investments owned by ALL members of the household. Include all savings accounts, checking accounts, Keogh accounts, annuities, certificate of deposits, real estate owned (must provide full market value of all real estate owned), stocks, bonds and all other assets owned.

Select All Assets*

Checking Account

Savings Account

Certificate of Deposits (CDs)

Stocks

Retirement Account

Life Insurance

Funded Debit

Other

Total Value of Assets*

Please explain "Other" Asset*

Do you own real estate?*

Yes

Market Value*

Have you disposed of an asset for less than "Fair Market Value" within the last two years?*

Yes

Date of Disposal*

Month

Day

Year

What was sold or converted to cash?*

Value of disposal*

Elderly / Disabled Household Information (Only if Qualified)

There is a deduction for every elderly/disabled household when calculating rent. An elderly household is one in which the head, co-head, or spouse is at least 62 years of age. A disabled household is one in which the head, co-head, or spouse is handicapped or disabled as defined by the agency providing subsidy (a verification form will be sent to a medical professional, but it does not inquire of the nature of the disability)

Would you like to be considered for the Elderly/Disabled Household allowance?*

Yes

Additional Information

Are you or any other adult household members a veteran of the armed forces?*

Yes

If yes, explain*

Do you or any other household members have pets?*

Yes

If yes, please list*

Have any household members ever committed any fraud in a federally assisted housing program or been required to repay money for knowingly misrepresenting information to such a program?*

Yes

If yes, explain*

Have any household members ever been evicted from any federally assisted housing unit for manufacturing and or distribution of methamphetamine in the home?*

Yes

Have any household members ever been convicted of a sex related crime or are they, or ever been, a registered sex offender in any state?*

Yes

If yes, explain*

Reasonable Accommodation Information

This information is voluntary. CRM Rental Management, Inc. is a management company that provides low rent housing to eligible households, elderly households and single people. CRM has a legal obligation to provide “reasonable accommodations” to applicants if they or any household member have a disability or handicap. You may request a reasonable accommodation at any time during the application process or after admission. If you would prefer to not discuss your situation with management, that is your right.

Does any member have special housing needs which require any of the following: (check applicable items)

Separate Bedroom

Unit for Vision Impaired

Unit for Hearing Impaired

Barrier-free Unit

One-level Unit

Bedroom/Bathroom on 1st Floor

Live-In Aide

Service Animal

Ramp

Other

Other: Please Specify*

I/we certify that the information given in this application is true to the best of my/our knowledge. I/we understand that any false information or any omission of any significant information is punishable by law, and could be grounds for cancellation of this application or termination of residency after occupancy.

This property does not discriminate on the basis of disability status in the admission of or access to, or treatment or employment in its federally assisted programs or activities.

It is illegal to discriminate against anyone because of race, color, creed, religion, sex, national origin, marital status, physical or mental disability or any other prohibited basis of discrimination. If you feel that you have been discriminated against, please contact The Management Company at (315) 337-1401.

ALL ADULTS, 18 YEARS OF AGE AND OLDER, LISTED ON THE APPLICATION WILL BE REQUIRED TO SIGN THE APPLICATION AND ITS ATTACHMENTS AS WELL AS PROVIDE A PICTURE IDENTIFICATION.

Confirm Information Is True & Correct

I have received assistance in completing this application, I have reviewed all answers and confirm that they are true and correct.

Head of Household Signature*

Date*

Month

Day

Year

Spouse or Co-tenant Signature

Date

Month

Day

Year

Other Adult Member Signature

Date

Month

Day

Year

Other Adult Member Signature

Date

Month

Day

Year

“Title 18, Section 1001 of the US 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). Violation of these provisions are cited as violations of 42 U.S.C. 408 (a), (6), (7) and (8).”

Applicant/Co-Applicant Consent Form

I/we hereby consent to allow CRM Rental Management through its' designated agent and its' employees, to obtain and verify my credit information (including a criminal background and sex offender status check) for the purpose of determining whether or not to lease me/us an apartment. I/we understand that should I/we lease an apartment, CRM Rental Management will review my/our criminal background and sex offender status yearly at recertification.

**PLEASE PRESENT PHOTO I.D. FOR ALL ADULTS IN HOUSEHOLD**

Head of Household Signature*

Date*

Month

Day

Year

Spouse or Co-tenant Signature

Date

Month

Day

Year

Other Adult Member Signature

Date

Month

Day

Year

Other Adult Member Signature

Date

Month

Day

Year

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).**

New York State Housing and Anti-Discrimination Disclosure Form

Federal, State and local Fair Housing and Anti-discrimination Laws provide comprehensive protections from discrimination in housing. It is unlawful for any property owner, landlord, property manager or other person who sells, rents or leases housing, to discriminate based on certain protected characteristics, which include, but are not limited to race, creed, color, national origin, sexual orientation, gender identity or expression, military status, sex, age, disability, marital status, lawful source of income or familial status. Real estate professionals must also comply with all Fair Housing and Anti-discrimination Laws.

Real estate brokers and real estate salespersons, and their employees and agents violate the Law if they:

Discriminate based on any protected characteristic when negotiating a sale, rental or lease, including representing that a property is not available when it is available.
Negotiate discriminatory terms of sale, rental or lease, such as stating a different price because of race, national origin or other protected characteristic.
Discriminate based on any protected characteristic because it is the preference of a seller or landlord.
Discriminate by “steering” which occurs when a real estate professional guides prospective buyers or renters towards or away from certain neighborhoods, locations or buildings, based on any protected characteristic.
Discriminate by “blockbusting” which occurs when a real estate professional represents that a change has occurred or may occur in future in the composition of a block, neighborhood or area, with respect to any protected characteristics, and that the change will lead to undesirable consequences for that area, such as lower property values, increase in crime, or decline in the quality of schools.
Discriminate by pressuring a client or employee to violate the Law.
Express any discrimination because of any protected characteristic by any statement, publication, advertisement, application, inquiry or any Fair Housing Law record.

YOU HAVE THE RIGHT TO FILE A COMPLAINT

If you believe you have been the victim of housing discrimination you should file a complaint with the New York State Division of Human Rights (DHR). Complaints may be filed by:

Downloading a complaint form from the DHR website: www.dhr.ny.gov;
Stop by a DHR office in person, or contact one of the Division’s offices, by telephone or by mail, to obtain a complaint form and/or other assistance in filing a complaint. A list of office locations is available online at: https://dhr.ny.gov/contact-us, and the Fair Housing HOTLINE at (844)-862-8703.

You may also file a complaint with the NYS Department of State, Division of Licensing Services. Complaints may be filed by:

Downloading a complaint form from the Department of State’s website https://www.dos.ny.gov/licensing/complaint_links.html
Stop by a Department’s office in person, or contact one of the Department’s offices, by telephone or by mail, to obtain a complaint form.
Call the Department at (518) 474-4429.

There is no fee charged to you for these services. It is unlawful for anyone to retaliate against you for filing a complaint/

For more information on Fair Housing Act rights and responsibilities please visit https://dhr.ny.gov/fairhousing and https://www.dos.ny.gov/licensing/fairhousing.html.

This form was provided to me by The Director of Compliance for CRM Rental Management, Inc.

I/We*

First Name Last Name

(Buyer/Tenant/Seller/Landlord) acknowledge receipt of a copy of this disclosure form:

Applicant Signature*

Date*

Month

Day

Year

Real Estate broker and real estate salespersons are required by New York State law to provide you with this Disclosure.

This form should be signed by office manager and applicant/tenant and then filed in the households correspondence file.

If the applicant/tenant refused to sign enter "declined to sign" on the applicant signature line. Office Manager should still sign and date in households correspondence file.

Supplemental and Optional Contact Information for HUD-Assisted Housing Applicant

This form is to be provided to each applicant for federally assisted housing

Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form.

Applicant Name

First Name Last Name

Mailing Address

Street Address Address Line 2 City State ZIP Code

Telephone No.

Cell Phone No.

Name of Additional Contact Person or Organization

First Name Last Name

Mailing Address

Street Address Address Line 2 City State ZIP Code

Telephone No.

Cell Phone No.

Relationship to Applicant

Reason for Contact

Check all that apply

Emergency

Unable to contact you

Termination of rental assistance

Eviction from unit

Late payment of rent

Assist with Recertification Process

Change in lease terms

Change in house rules

Other

Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you.

Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law.

Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992) requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of 1975.

Do not want to provide information.

Check this box if you choose not to provide the contact information.

Signature of Applicant

Date

Month

Day

Year

The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information. Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the collection displays a currently valid OMB control number.

Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions.

Authorization for Release of Information

CONSENT:

I authorize and direct any Federal, State, or local agency, organization, business, or individual to release to CRM Rental Management, Inc. any information or materials needed to complete and verify my application for participation, and/or to maintain my continued assistance under one of the following programs:

Section 221 BMIR
Rent Supplement
Section 236
DHCR
LIHTC Program
Rural Development
Rural Rental Assistance Payments (RRAP)
HUD Section 8 Housing Assistance (LMSA, PRAC, etc.) Payments Programs
HOME
Housing Trust Fund

I give my consent for the release also for the minor children in my care who live with me. I understand and agree that this authorization or the information obtained with its use may be given to and used by the Department of Housing and Urban Development (HUD) and Rural Development (RD) in administering and enforcing program rules and policies.

INFORMATION COVERED:

I understand that, depending on program policies and requirements, previous or current information regarding me or my household may be needed. Verification's and inquiries that may be requested include, but are not limited to:

Identity and Marital Status
Residences and Rental Activity
Credit and Criminal Activity
Employment, Income, and Assets
Medical or Child Care Expenses
Social Security Numbers

I understand that this authorization cannot be used to obtain any information about me that is not pertinent to my eligibility for and continued participation in a housing assistance program.

GROUPS OR INDIVIDUALS THAT MAY BE ASKED

The groups or individuals that may be asked to release the above information (depending on program requirements) include, but are not limited to:

Previous Landlords
Public Housing Agencies
Welfare Agencies
Post Offices
Banks and Financial Institutions
Social Security Administration
Support and Alimony Providers
Utility Companies
Past and Present Employers
Veterans Administration
Retirement Systems
State Unemployment Agencies
Schools and Colleges
Credit Providers and Credit Providers
Realtors and Insurance Agencies

COMPUTER MATCHING

I understand and agree that HUD or a Public Housing Authority (PHA) may conduct computer matching programs to verify the information supplied for my certification or recertification. If a computer match is done, I understand that I have a right to notification of any adverse information found and a chance to disprove incorrect information. HUD or the PHA may in the course of its duties exchange such automated information with other Federal, State, or local agencies including, but not limited to: State Employment Security Agencies; Department of Defense; Office of Personnel Management; the U.S. Postal Service; the Social Security Agency; and State welfare and food stamp agencies.

CONDITIONS

I agree that a photocopy of this authorization may be used for the purposes stated above. The original of this authorization is on file with the management office and will stay in effect for a year and one month from the date signed. I understand I have a right to review my file and correct any information that I can prove is correct.

Applicant Name

First Name Last Name

Signature of Applicant

Date

Month

Day

Year

Applicant Name

First Name Last Name

Signature of Applicant

Date

Month

Day

Year

NOTE: THIS GENERAL CONSENT MAY NOT BE USED TO REQUEST A COPY OF A TAX RETURN. IF A COPY OF A TAX RETURN IS NEEDED, IRS FORM 4506, "REQUEST FOR COPY OF TAX FORM" MUST BE PREPARED AND SIGNED SEPARATELY.

"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).**

Phone

This field is for validation purposes and should be left unchanged.