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 in admission to, access to, treatment in, or employment within its federally-assisted programs or activities.

It is illegal to discriminate against individual on the basis of race, color, creed, religion, sex, national origin, marital status, physical or mental disability, or any other protected characteristic. If you believe you have experience discrimination, please contact CRM Rental Management, Inc. at (315) 337-1401.

ALL ADULTS AGED 18 AND OLDER LISTED ON THE APPLICATION ARE REQUIRED TO SIGN THE APPLICATION AND ITS ATTACHMENTS AND PROVIDE VALID PHOTO IDENTIFICATION.

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.

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

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.

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.

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.

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.

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.