VERIFICATION OF U.S. Department of Housing OMB ... - HUD

VERIFICATION OF DISABILITY

AALLLL PPRROOGRAMS EXCEPT

SECTION 202/8, SECTION 202 PAC, SECTION 202 PRAC, AND SECTION 811 PRAC

U.S. Department of Housing and Urban Development

Office of Housing Federal Housing Commissioner

OMB Approval No. 2502-0204 (Exp. 06/30/2017)

Appennddiixx66--BB:: SAAMMPPLLEE VVEERRIFICAATTION OF DISABBIILLIITTYY WWHHEN ELLIIGIBBIILLIITTYY FFOORR AADDMMIISSSSIION OR QUALIFICATION FOR CERTAIN INCOME DEDUCTIONSS IISS BBASED ON DISSAABILITY

FOR USE WITH ALL PROGRAAMMSS EXCEPT SECTION 202/8, SECTION 202 PAC, SECTION 202 PRAC, AND SECTION 811 PRAC

DATE:

TO:

FROM:

RETTUURRNNTTHHIISSVVEERRIFIFICICAATTIOIONNTTOOTTHHEEPEPRESROSNONLILSITSETDEDABAOBVOEV(Eor(oorthotehreirnisntsrutrcutcitoionnsstotoththeetthhiirrdd pparty to ensure that the verificcaattiioonn iissrreettuurrnneeddttootthheerrigighhttppeerrssoonn.. This is iimmppoorrttaannttbbeeccaauussee oowwnneerrss hhaave a responsibilittyy ttoo ttrreeat this information confidentially.)

SUBJECT: Veerriification of Diisaabbiility

NAME___________________________________________________________

ADDRESS____________________________________________________________________________

This person has applied forr hhoouussiinnggaassssiissttaanncceeuunnddeerraa pprrooggrraammoofftthheeUU..SS. Department of Housing and Urban Deevveellopment (HHUUDD))..HHUUDDrerqeuqiureirsesthtehehohuosuisninggoowwnneer rtotovveerirfiyfyaallllininffoorrmmaattiioonn tthhaatt iis used in determining this person''s eelligibilittyy orr lleevel of benefits.

Wee aasskkyyoouurrccooooppeerraattiioonniinnpprroovviiddiing thee ffoolllowing information and returning it to the person listteed at the top of the page. YYoouurrpprorommppttreretuturrnnooffththisisininffoorrmmaattiioonn wwiilll heellp to eennssuuree ttiimeelly processing of the appliccaattiioonnffoorraassssisistatannccee.. Enclosed iss a selff--addrreesssseedd,, ssttaammppeedd eenvveellooppee ffoorr tthhiissppuurrppoossee.. The applicant/tenant has consented to this release of information as shown above.

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INFORMATION BEING REQUESTED

For eaacch nnumbeerreedd iitteemm bbeellooww,, mmaarrkkaann""XX"" iin the aappppllicable box that aacccurately describes the person listteed above.

1. ___YES ___NO

Has a ddisabiliittyy,, aass ddeeffiinneeddiinn4422 UU..S.C. 42233,, wwhhiich meaanns;

a. Inability ttoo engage in any substantial gainful activittyy bbyy rreeason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of nott lleesss tthhaan 12 months; or

APPENDIX 6-B

1 of 4

form HHUUDD--99001103 (12/2007) ref. HB 4350.3 Rev. 1

SAMPLE VERIFICATION OF DISABILITY

AALLLL PPRROOGRAMS EXCEPT

SECTION 202/8, SECTION 202 PAC, SECTION 202 PRAC, AND SECTION 811 PRAC

U.S. Department of Housing and Urban Development

Office of Housing Federal Housing Commissioner

OMB Approval No. 2502-0204 (Exp. 06/30/2017)

2. ___YES ___NO 3. ___YES ___NO

b. In the case of an indiviidduuaall wwhhoo hhaass aattttaaiinneedd tthhee aagge of 55 and is blind, inabiliittyy bbyy rreeaason of such bliinnddnneess ttoo engage in substantial gainful activity requiriinngg sskkiilllssoorraabbiilliittieiessccoommppaarraabbllee ttoo tthhoossee of any gainful activiittyy iinnwwhhiicchhhhee//sshhee has previousllyy eengaged with some regularity and over a substantial period of time.

For the purposes of this definitiioonn,, tthhee term blinddnneess, as defined in section 416(i)(11)) ooff tthis titllee, means central visiioonn aaccuuiittyyooff2200//2200 or less in thhee bettteer eye withh uussee off a corrrreeccttiinngglleennss.. An eyee wwhhiich is accompanied bby aa lliimmiitaattion in the fields of vision such that the widest diameter of the visual fiieelldd ssuubbtteennddssaann aannggllee nnoo ggrreeaatteer tthhaan 20 degrees shaall be cconsidered for the purposes of thiss paragraph as having a central visuuaall acuiittyy ooff2200/200 or less.

Has aa pphhyyssiical, mmeennttaall,, oorr eemmoottiioonaall iimpaaiirmennt that: a. Is expected tto bbee ooff lloonngg--ccoonnttinued aanndd iinnddeeffiinniite dduuraattion; bb.. Substantially impedes his or her abbility to livvee independently; and cc.. Is of such a nature thatt the aabbiillity to live independently could be

improved by more ssuuiitabblee hhoouussiing ccoonnddiitions.

Has aa ddeevveellooppmeennttaall ddisabilittyy aas defiinneedd iinn SSecttiioonn 11002(7) of the Deveellopmenntal DDiisaabbiilities Assiissttaannccee aand BiillllooffRRiigghhttssAAcctt4422UU..SS.C. 600011((88)))),,i.i.ee.,.,aappeersrsoonnwwitihthaasseevveererecchhroronnicicddisisaabbiilliitty that:

a. Is attributtaabllee to a mental or physical impairment or combination of mental and physical impairments;

b. Is manifested before the person attainnss aage 22;

c.

Is likely to continue indeeffinitely;

d. Reessuullts in substantial functional liimmiittaattiioonn iinn tthhrreeee orr more of the following areas of mmaajjoorr lliife aaccttiivviity:

(1) Self-care,

(2) Reecceepptive and eexxpressive language,

(3) Learning,

(4) Mobbiility,

(5) Seellf-direction,

(6) Caappaacciity for independent living, and

(7) Economic seellf-sufficiency; and

e. Reflects the person's need for a combinatiioonn aand sequence of special, interdisciipplliinnaarryy,,oorrggeenneerriicc ccaarree, trreeatment, or other services that are of lifelong or extended duration and aarree iinnddividually planned and coordinated.

APPEENNDDIX 6-B

2 of 4

form HHUUDD--9900103 (12/2007) ref. HB 4350.3 Rev. 1

SAMPLE VERIFICATION OF DISABILITY

AALLLL PPRROOGRAMS EXCEPT

SECTION 202/8, SECTION 202 PAC, SECTION 202 PRAC, AND SECTION 811 PRAC

U.S. Department of Housing and Urban Development

Office of Housing Federal Housing Commissioner

OMB Approval No. 2502-0204 (Exp. 06/30/2017)

4. ___YES ___NO

Is the above a ppeerrson whose disabiliittyy iissbbaasseedd ssolely on any drug or alcohol dependence ((tthee ppeerrssoonn hhaass nnoo ootthheerr ddiissaabbiility which meets the above ddeeffiinition).

____________________________ NAME AND TITLE OF PERSON SUPPLYING THE INFORMATION

____________________________ SIGNATURE

_______________________________ FIRM/ORGANIZATION

________________________________ DATE

============================================================================

Public reporting burden for this collection is estimated to average 12 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. This information is required to obtain benefits and is voluntary. HUD may not collect this information, and you are not required to complete this form, unless it dissppllaayyss aa ccuurrrreennttllyy vvaalliiddOOMMBBccoonnttrroollnnuummbbeerr.. Owners/management agents must obtain third party verification that a disabled individual meets the definition for persons with disabilities for the program governing the housing where the individual is applying to live. The defminitions for persons with disabilities for programs covered under the United States Housing Act of 1937 are in 24 CFR 403 and for the Section 202 and Section 811 Supportive Housing for the Elderly and Persons with Disabilities in 24 CFFRR 889911..330055 aanndd 889911..550055.. NNoo aassssuurrance of confidentiality is provided.

The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937, as amended (42 U.S.C. 1437 et. seq.); the Housing and Urban-Rural Recovery Act of 1983 (P.L. 98-181); the Housing and Community Development Technical Amendments of 1984 (P.L. 98-479); and by the Housing and Community Development Act of 1987 (42 U.S.C. 3543).

APPEENNDDIX 6-B

3 of 4

form HHUUDD--99001103 (12/2007) rreeff. HHBB4433550.3 Rev. 1

SAMPLE VERIFICATION OF DISABILITY

AALLL PROGRAMS EXCEPT

SECTION 202/8, SECTION 202 PAC, SECTION 202 PRAC, AND SECTION 811 PRAC

U.S. Department of Housing and Urban Development

Office of Housing Federal Housing Commissioner

OMB Approval No. 2502-0204 (Exp.06/30/2017)

======================================================================== RELEEAASSEE:: I Ihheererebbyyaauuththoorirzizeeththeerereleleaasseeoof fththeerereqquueestseteddininfoformrmaatitoionn..InInfoforrmmaatitoionnoobbttaaiinneedduunnddeerrtthhiiss cconsent is limitteed ttoo iinnffoorrmmaattiioonntthhaattisisnnooooldldeerrththaann1122mmoonntthhss.. Theerree aarreecciirrccuummssttaanncceess tthhaatt wwoouulld require the owner to verify inforrmmaatiioonn tthhaatt iissuuppttoo55 yyeeaarrss oolldd,, wwhhiicchhwwoouuldldbbeeaauutthhoorrizizeeddbbyymmeeoonnaa sseeppaarate consent attached to a copy of this consent.

Signature

Date

Nottee ttooAApppplilcicaannt/tT/Teennanatn:tY: oYuoduodnoontohtahvaevteotsoigsnignthtihsisfofromrmifief iethitheer rththeerereqquueesstitninggoorrggaannizizaattioionnoorr tthhee oorrggaanniizaattion supplying the information is left blank.

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PENALTIES FOR MISUSING THIS CONSENT:

Title 18, SSeeccttiioon 11000011oofftthheeUU.S.S. .CCooddeesstatatetessththaat taapperesrosonnisisgguuilitlytyooffaafefelolonnyyfoforrkknnoowwininggllyy aannddwwiillllingly making false or frauduulleenntt ssttaatteemmeennttssttooaannyyddeeppaarrtmtmeennttooffththeeUUnnitieteddSStatatetessGGoovveernrnmmeennt.t. HHUD and any owner (or any emplooyyeee off HUD or the owner) maayy bbeessuubbjjeecctt ttoo ppeennaallttiieessffoorr uunnaauutthhoorriizzeedd ddiisscclosures or improper uses of information colllleecctteedd based on the consent form. UUsseeooffththeeininfoforrmmaatitoionnccoollleecctteeddbbaasseeddoonnththisisvveerriiffiiccaattiioonn fform is restricted to the purposes citteed above. Any person who knowingly or williinnggllyy rreeqquueessttss,, oobbttaaiinnss,, orr diisscclloosseess aannyy iinnffoorrmmaattiioonnuunnddeerr ffaallssee pprreetteenses concerning an appliccantt oorr ppaarrttiiccipipaannttmmaayybbeessuubbjejeccttttooaammiissddeemmeeaannoorraannddffiinneeddnnoottmmoorreetthhaann$$55,,00000. AAnnyyaapppplliiccaanntt oorr ppaarrtticipant affected by negligent discloossuurree off iinnffoorrmmaattiioonnmmaayy bbrriinnggcciivvililaacctitoionnfoforrddaammaaggeessaannddsseeeekk ootthheerr rreelliieeff,, aass may be appropriate, against the offiicceerr oorr eempllooyyeeee off HUD or the owner responsiblee forr tthhee unnaautthhoorriizzeedd ddiisscclloossuurreeoorrimimpprrooppeerruussee.. Penalty proviissiioonnssffoorrmmisisuussininggththeessoocciaial lsseeccuurirtiytynnuummbebreraarereccoonntataininededininthteheSSoocicailaSl SeeccuurirtyityAActcat ta2t 02808(a(a))(6(6)),,((77)) aandd (8). Violatioonnss oofftthheesseepprroovvisisioionnssaarereccitieteddaassvvioiolaltaiotinosnsofo4f 242UUSSCC440088(a(a),),((66)),,((77)) aandd (8).

EQUAL HOUSING OPPORTUNITY

APPPEENNDDIIX 6-B

4 of 4

form HHUUDD--99001103 (12/2007) ref. HHBB 4433550.3 Rev. 1

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