Statement of No Income Certification - NHE Inc



NHE, Inc.

(ENTER PROPERTY NAME)

STATEMENT OF NO-INCOME CERTIFICATION

In accordance with HUD regulations governing the gross income for all sources, I certify that I currently have no source(s) of income. I agree to report every 90 days to the office to inform them of my income status.

I understand that the HUD EIV system will continue to “validate” my social security number against the IRS and HHS databases for the following:

1. EIV will be used to verify the employment and income of individuals receiving Section 8 assistance of all residents at the time of annual or interim recertifications.

2. EIV will be used to determine if residents have started new employment within the past months, quarterly wage information for past or current employment, unemployment benefits, and social security benefits.

I ( Did ( Did Not File a Federal Income Tax Report Last Year .

Furthermore, I acknowledge the need to inform the manager immediately when I do begin to receive income from any source.

PLEASE TAKE NOTICE that your failure to report income will lead to your rental assistance being terminated. Your lease requires that you must report any income to enable the manager to process your recertification.

WARNING: 1010 of Title 18 of the United States code makes it a criminal offense to make willfully false statements or misrepresentation to any Department or Agency of the United States as to any matter within its jurisdiction.

/ /

Resident Signature Date

Unit #

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, the PHA and any Owner (or employee of HUD, the PHA 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 $5000. 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 PHA 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 42 U.S.C. a(208)(6)(7) and (8). Violation of these provisions are cited as violations of 42 U.S.C. 408 a (6), (7) and (8).

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download