NEW YORK CITY HOUSING AUTHORITY LEASED HOUSING …

NEW YORK CITY HOUSING AUTHORITY LEASED HOUSING DEPARTMENT

SEcTION 8 HOUSING cHOIcE vOUcHER PROGRAM

DECLARATION OF CITIZENSHIP STATUS

Section 8 Voucher #

THE NEW YORK CITY HOUSING AUTHORITY IS REQUIRED TO OBTAIN INFORMATION REGARDING THE CITIZENSHIP STATUS OF EACH AUTHORIZED OCCUPANT IN YOUR APARTMENT TO DETERMINE ELIGIBILITY FOR RENTAL ASSISTANCE IN FEDERALLY-ASSISTED HOUSING. BY SUBMITTING THIS FORM, YOU DECLARE UNDER PENALTIES OF PERJURY THAT ALL STATEMENTS WRITTEN ON THIS DOCUMENT ARE TRUE AND CORRECT.

Warning: 18 U.S.C 1001 provides, among other things, that whoever knowingly and willfully makes or uses a document or writing containing any false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any department or agency of the United States, shall be fined not more than $10,000, imprisoned for not more than 5 years, or both.

NOTE: PLEASE READ THE ATTACHED INSTRUCTION SHEET AND FILL OUT ALL THE INFORMATION REQUESTED BELOW. USE A SEPARATE LINE FOR EACH TENANT OR AUTHORIZED MEMBER OF THE HOUSEHOLD.

Items 1-4 Must be completed for each authorized occupant. Item 5 Complete only if the family member is a United States Citizen (by birth, naturalized citizen or a national of the United States). Items 6-8 Complete only if the family member is a Non-Citizen that has eligible immigration status.

You must submit documentation as proof of your status (see instructions)

Item 9 Complete only if the family member is a Non-Citizen and does NOT claim to have eligible immigration status.

CONSENT: Family members consent to all the Housing Authority to obtain information and/or to release information of immigration status, as required by law, to the United States Department of Housing and Urban Development (HUD) and Natural Service (INS) for purposes of verifying claimed immigration status. The Housing Authority is not responsible for the further use or transmission of evidence of immigration status by HUD or INS. Evidence of eligible immigration status shall only be released by HUD to INS for purposes of establishing eligibility for financial assistance and not for any other purposes. HUD is not responsible for further use of transmission of the evidence or other information by the INS.

1. PRINT YOUR FULL NAME and the name of each authorized occupant in your household.

2. SOCIAL SECURITY NUMBER (if available)

3. DATE OF BIRTH

4. SIGNATURES (if occupant listed in item 1 is under 18, legal guardian must sign)

NON-CITIZENS WITH ELIGIBLE IMMIGRATION STATUS

6. WITH Eligible Status (mark "X")

7. Alien Registration # Or I-94 #

8. Nationality

1. Last

First

MI

5. U.S. CITIZEN (mark "X")

9. NO Eligible Status (mark "X")

2. Social Security #

3. Date of Birth (mm/dd/yyyy)

4. Signature

5.

6.

7. Alien Registration # or I-94 #

8. Nationality

9.

1. Last

3. Date of Birth (mm/dd/yyyy)

4. Signature

6.

7. Alien Registration # or I-94 #

First

MI

2. Social Security #

5.

8. Nationality

9.

NYCHA 059.616 (Rev. 1/31/12v3) VS_20120111 SEC. 8 HOUSING CHOICE VOUCHER PROGRAM 1 of 2

1. PRINT YOUR FULL NAME and the name of each authorized occupant in your household.

2. SOCIAL SECURITY NUMBER (if available)

3. DATE OF BIRTH

4. SIGNATURES (if occupant listed in item 1 is under 18, legal guardian must sign) NON-CITIZENS WITH ELIGIBLE IMMIGRATION STATUS

5. U.S. CITIZEN (mark "X")

6. WITH Eligible Status (mark "X")

7. Alien Registration # Or I-94 #

8. Nationality

9. NO Eligible Status (mark "X")

1. Last

First

MI

2. Social Security #

3. Date of Birth (mm/dd/yyyy)

4. Signature

5.

6.

7. Alien Registration # or I-94 #

8. Nationality

9.

1. Last

3. Date of Birth (mm/dd/yyyy)

4. Signature

6.

7. Alien Registration # or I-94 #

First 8. Nationality

MI

2. Social Security #

5.

9.

1. Last

3. Date of Birth (mm/dd/yyyy)

4. Signature

6.

7. Alien Registration # or I-94 #

First 8. Nationality

MI

2. Social Security #

5.

9.

1. Last

3. Date of Birth (mm/dd/yyyy)

4. Signature

6.

7. Alien Registration # or I-94 #

First 8. Nationality

MI

2. Social Security #

5.

9.

1. Last

3. Date of Birth (mm/dd/yyyy)

4. Signature

6.

7. Alien Registration # or I-94 #

First 8. Nationality

MI

2. Social Security #

5.

9.

1. Last

3. Date of Birth (mm/dd/yyyy)

4. Signature

6.

7. Alien Registration # or I-94 #

First 8. Nationality

MI

2. Social Security #

5.

9.

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