Certification
Section 8 Tenant-Based Assistance
Rental Voucher Program
Tenant ID
WARNING: BY SIGNING THIS FORM, YOU ARE INDICATING THAT YOU HAVE READ AND ARE AGREEING
WITH ITS CONTENTS
UNIT ADDRESS 1015 Sadie Street ANNUAL INCOME
FORNEY, TX 75126 GROSS 42,204
ADJUSTED 39,404
CONTRACT RENT 2,150
OCCUPANTS JAZMINE M. KEA TENANT SHARE 670
BASH J. COPELAND IV SECTION 8 SHARE 1,480
JANIYA M. KEA
UTILITY ALLOWANCE 315
JANELLE M. COBBIN
UTILITY REIMBURSEMENT 0
DAMARI L. KINNEY
VANEOUS R. WRIGHT III
EFFECTIVE DATE 06/01/2022
FEDERAL PRIVACY ACT NOTICE
PURPOSE: Family income and other information is being collected by the Department of Housing and Urban Development (HUD) to
determine an applicant's eligibility, the recommended unit size, and the amount the family must pay toward rent and utilities.
USE: HUD uses family income and other information to assist in managing and monitoring HUD-assisted housing programs; to protect
the Government's financial interest; and to verify the accuracy of the information furnished. HUD or a public housing agency/Indian
housing authority may conduct a computer match to verify the information you provided. This information may be released to appro-
priate Federal, State, and local agencies, when relevant, and to civil, criminal and regulatory investigators and prosecutors. However,
the information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law.
PENALTY: You must provide all of the information requested by the public housing agency/Indian housing authority, including all social
security numbers you, and all other household members age six (6) years and older, have and use. Giving the social security numbers
of all household members 6 years of age and older is mandatory, and not providing the social security numbers will affect your eligibility.
Failure to provide any of the requested information may result in a delay or rejection of your eligibility approval.
AUTHORITY FOR INFORMATION COLLECTION: The following laws authorize the collection of this information by HUD or the public
housing agency/Indian housing authority: the U.S. Housing Act of 1937 (42 U.S.C., 1437 et seq.), Title VI of the Civil Rights Acts of
1964, and Title VIII of the Civil Rights Act of 1968. The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires
applicants and residents to submit the social security numbers of all household members at least six (6) years old.
TENANT(S)' CERTIFICATION
Under the penalty of perjury, I/We certify that the information provided is true and complete to the best of my/our knowledge
and belief. I/We understand that we can be fined up to $10,000, or imprisoned up to five years, or lose the subsidy HUD pays
and have my/our rent increased, if I/we furnish false or incomplete information.
AGENT CERTIFICATION
I certify that this tenant's eligibility, rent and assistance payment have been computed in accordance with HUD's regulations and
administrative procedures and that all required verifications were obtained.
#HOHTenant #HOHTenantTimestamp
JAZMINE M. KEA Head of Household Date
#HOHTenantUser
#CoHead #CoHeadTimestamp #Agency #AgencyTimestamp
Spouse/Co-Head Date TANYMA ALLEN, HOUSING OCCUPANCY Date
#CoHeadUser TECHNICIAN
#AgencyUser
Document ID: 12733181885
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