Date Received: Time Received: Application taken by:

APPLICATION FOR HOUSING

Project Base Section 8 Property/ Low-Income Housing Tax Credit Property
This is an application for housing at: DCA 1, LP
477 Howard Avenue, Mgmt Office
Brooklyn, NY 11233
TEL (718) 573-8506*FAX (917) 722-6246 *TTY (800 421-1220
www.reliantrs.com
Please complete this application and return to the address above. Please Print Clearly.
Applications are placed in order of date and time received. An applicant may be interviewed only after the receipt
of this tenant application. ANY QUESTIONS THAT DO NOT APPLY, PLEASE MARK “NONE” OR “$0.00”.
DO NOT LEAVE ANY BLANK LINES.
A. APPLICANT AND FAMILY INFORMATION
List ALL permanent household members who will live in the apartment home during the next 12 months. Be sure to list any
temporarily absent family members, foster children/adults, unborn children or Live In Care Attendants.

Name Relationship Date Age Sex Social Security #* Are you a

to head of Student?
household of List “No”,
Birth “Part
Time”, or
“Full
Time”
Head Self
Co-Head
3.
4.
5.
6.
7.
8.
* Disclosure of SSNs is required for the applicant and for all members of the applicant’s household, except those household
members who do not contend eligible immigration status.
Do you anticipate any additions to the household in the next twelve months? YES NO
If yes, explain
Applicants who were age 62 or older as of January 31, 2010 and who do not have a social security number
-Were you receiving HUD rental assistance at another location on January 31, 2010? YES NO
Are all members of the household U.S. citizens or permanent resident aliens? YES NO

Address: Street
Apt. # City State Zip

Home/Cell Phone: Work Phone: Other Phone:

Email:

Bedroom size requested: Studio  One Bedroom Two Bedroom Three Bedroom

DCA 1, LP does not discriminate on the basis of disability in the admission or access to, or treatment or employment in, its federally assisted programs and
activities. Dana Padilla has been designated to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and
Urban Development’s regulations implementing Section 504 (24 CFR, part 8 dated June 2, 1988). You may address your request for review or reconsideration
to: D. Padilla, Reliant Realty Services, 909 Third Avenue, 21st Floor, New York, NY 10022, (646) 374-0100, NY TTY 1-800-662-1220.
Rev. 2020
 Do you desire an apartment with accessible features? Yes No (check one)

If so, what features?

B. STUDENT STATUS INFORMATION

Will all of the persons in the household be or have been full-time students during five calendar months of this year or
plan to be in the next calendar year at an educational institution (other than a correspondence school) with regular
faculty and students? YES NO
IF YES, ANSWER THE FOLLOWING QUESTIONS:
Are any full-time student(s) married and filing a joint tax return?  YES  NO
Are any student(s) enrolled in a job-training program receiving assistance under the Job  YES  NO
Training Partnership Act?
Are any full-time student(s) a TANF or a Title IV recipient?  YES  NO
Are any full-time student(s) a single parent living with his/her minor child who is not a  YES  NO
Dependant on another’s tax return?
Are any full-time student(s) considered Independent Students? Definition of an  YES  NO
Independent Student consists of individuals who were an orphan, in foster care of ward
of the court at the age of 13. This definition also includes students who are or were
emancipated or in legal guardianship; unaccompanied youths who are homeless or risk of
homelessness – vulnerable youth populations.

C. EMPLOYMENT INFORMATION
Employer:
Gross Monthly Income $
including bonuses, overtime, tips, commission, etc.
Head of Household Employer Date Started:
Position Held:
Do you have a second job? Yes No
If yes, where Gross Monthly Income $

Employer:
Gross Monthly Income $
including bonuses, overtime, tips, commission, etc.
Co-head/ Roommate Employer Date Started:
Position Held:
Do you have a second job? Yes No
If yes, where Gross Monthly Income $

Employer:
Gross Monthly Income $
including bonuses, overtime, tips, commission, etc.
Co-head/ Roommate Employer Date Started:
Position Held:
Do you have a second job? Yes No
If yes, where Gross Monthly Income $

DCA 1, LP does not discriminate on the basis of disability in the admission or access to, or treatment or employment in, its federally assisted programs and
activities. Dana Padilla has been designated to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and
Urban Development’s regulations implementing Section 504 (24 CFR, part 8 dated June 2, 1988). You may address your request for review or reconsideration
to: D. Padilla, Reliant Realty Services, 909 Third Avenue, 21st Floor, New York, NY 10022, (646) 374-0100, NY TTY 1-800-662-1220.
Rev. 2020
 D. ADJUSTED INCOME DEDUCTIONS
For family households only- List below any amounts paid by you for child care expenses for family members below 13
years of age which enable you to be gainfully employed or to attend school on a full-time basis.
Paid to: Monthly Amount Paid:
For elderly/disabled households only- (Head of Household or Spouse is over 62 years old, is handicapped or disabled).
List below any medical expenses that you currently pay.
Paid to: Monthly Amount Paid:

E. INCOME INFORMATION
Please indicate each source of income received or anticipated within the next 12 months
DESCRIPTION OF INCOME RECEIVES NOW OR IF YES, HOUSEHOLD GROSS AMOUNT
OR STATUS ANTICIPATES MEMBER NAME RECEIVED
RECEIVING MONTHLY
(Must check Yes or No)
HOH Employment/ Anticipated
 YES  NO $
Employment
Co-head/ Roommate
Employment/ Anticipated  YES  NO $
Employment
Self- Employment  YES  NO $
Military Pay  YES  NO $
Alimony  YES  NO $
Child Support  YES  NO $
Unemployment Benefits  YES  NO $
Social Security  YES  NO $
SSI, SSD  YES  NO $
V.A. Benefits  YES  NO $
Public Assistance  YES  NO $
Disability, Worker’s Comp.  YES  NO $
Recurring Gift of monetary
 YES  NO $
value
Regular Payments from
 YES  NO $
Retirement Account
Regular Payments from Trust
 YES  NO $
Account
Scholarships  YES  NO $
Grants  YES  NO $
Insurance Policies, Death and
 YES  NO $
Disability Benefits
Income from Rental Property  YES  NO $
Other: Type  YES  NO $

DCA 1, LP does not discriminate on the basis of disability in the admission or access to, or treatment or employment in, its federally assisted programs and
activities. Dana Padilla has been designated to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and
Urban Development’s regulations implementing Section 504 (24 CFR, part 8 dated June 2, 1988). You may address your request for review or reconsideration
to: D. Padilla, Reliant Realty Services, 909 Third Avenue, 21st Floor, New York, NY 10022, (646) 374-0100, NY TTY 1-800-662-1220.
Rev. 2020
 F. ASSETS
Please include all assets, including assets for children
DESCRIPTION OF ASSET CURRENTLY HAVE IF YES, HOUSEHOLD VALUE
MEMBER NAME
Cash on hand  YES  NO $
Checking Account (6 mo. Avg.
 YES  NO $
balance)
Savings Account (current
balance)  YES  NO $
CDs, Money Market, Mutual
 YES  NO $
Funds, Stocks
IRA, 401K, Pensions, Annuities  YES  NO $
Life insurance policy (Whole)  YES  NO $
Real Estate currently owned/
 YES  NO $
Rental Property
Assets disposed of for less than
 YES  NO $
Fair Market Value in past 2 yrs
Have you received any lump sum
payments such as Inheritance,
Lottery winnings, Insurance  YES  NO $
settlements, Etc.
Prepaid/EBT Card  YES  NO $
Other:  YES  NO $

G. REFERENCE INFORMATION
CURRENT LANDLORD
Landlord Name
Address
Phone
Month and year moved in:
Reason for moving:
No. of BR’s in current unit:
Do you Rent of Own?
Amount of current monthly rental or
mortgage payment?

H. ADDITONAL INFORMATION
Are you or any member of your family currently using an illegal substance?  YES NO
Have you or any member of your family been evicted due to drug activity in the past 3  YES NO
years?
Have you or any member of your family ever been convicted of a felony?  YES NO
If yes, describe:
Have you or any member of your family ever been evicted from housing?  YES NO
If yes, describe:

DCA 1, LP does not discriminate on the basis of disability in the admission or access to, or treatment or employment in, its federally assisted programs and
activities. Dana Padilla has been designated to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and
Urban Development’s regulations implementing Section 504 (24 CFR, part 8 dated June 2, 1988). You may address your request for review or reconsideration
to: D. Padilla, Reliant Realty Services, 909 Third Avenue, 21st Floor, New York, NY 10022, (646) 374-0100, NY TTY 1-800-662-1220.
Rev. 2020
 I. EMERGENCY CONTACT
In case of emergency notify:
Address:
Relationship: Phone #

J. VEHICLE INFORMATION (if applicable)

List any cars, trucks, or other vehicles owned.
Type of Vehicle: License Plate #:
Year/Make: Color:
Type of Vehicle: License Plate #:
Year/Make: Color:

K. PET INFORMATION (if applicable)

Please be aware that Property Name LP does not permit pets. Service animals are not considered pets.
Do you own any pets?  YES NO
If yes, describe:

Please list every State that each member of the household member has resided in:
Head of Household:
Member 2:
Member 3:
Member 4:
Member 5:
Member 6:
Member 7:
Member 8:
Is any member of your household subject to a lifetime sex offender registration requirement in any State?
 YES NO
I understand that should it be discovered that a member of my household is subject to a lifetime registration requirement at
admission, management will immediately pursue eviction and termination of assistance for the household member
 YES NO

Ethnic Categories (select one): Not of Hispanic, Latino/a, or Spanish Origin Hispanic, Latino/a, or
Spanish Origin Declined to Report

Racial Categories (select one or more): American Indian or Alaska Native Asian White
 Black or African American Native Hawaiian or Other Pacific Islander Other
 Declined to Report

Marketing Information:
How did you hear about the property?
 www.reliantrs.com Walk By Flyer
 Apartment Guide Rent.com Apartments.com Craigslist GoSection8.com
 Newspaper (which paper? )
 Housing Authority (specify agency )
 Tenant Referral (who can we thank? )
 Other (specify )

DCA 1, LP does not discriminate on the basis of disability in the admission or access to, or treatment or employment in, its federally assisted programs and
activities. Dana Padilla has been designated to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and
Urban Development’s regulations implementing Section 504 (24 CFR, part 8 dated June 2, 1988). You may address your request for review or reconsideration
to: D. Padilla, Reliant Realty Services, 909 Third Avenue, 21st Floor, New York, NY 10022, (646) 374-0100, NY TTY 1-800-662-1220.
Rev. 2020
 CERTIFICATION
I/We hereby certify that I/WE DO/WE WILL not maintain a separate subsidized rental unit in another location. I/We further
certify that this will be my/our permanent residence. I/We understand I/We must pay a security deposit for this apartment
prior to occupancy. I/We understand that my eligibility for housing will be based on applicable income limits and by
management’s selection criteria. I/We certify that all information in this application is true to the best of my/our knowledge
and I/We understand that false statements or information are punishable by law and will lead to cancellation of this
application or termination of tenancy after occupancy. All adult applicants, 18 or older, must sign this application.

SIGNATURE (S):

(Signature of Tenant) Date

(Signature of Tenant) Date

(Signature of Tenant) Date

(Signature of Tenant) Date

DCA 1, LP does not discriminate on the basis of disability in the admission or access to, or treatment or employment in, its federally assisted programs and
activities. Dana Padilla has been designated to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and
Urban Development’s regulations implementing Section 504 (24 CFR, part 8 dated June 2, 1988). You may address your request for review or reconsideration
to: D. Padilla, Reliant Realty Services, 909 Third Avenue, 21st Floor, New York, NY 10022, (646) 374-0100, NY TTY 1-800-662-1220.
Rev. 2020
 NOTICE OF OCCUPANCY RIGHTS UNDER U.S. Department of Housing and Urban Development
THE VIOLENCE AGAINST WOMEN ACT OMB Approval No. 2577-0286
Expires 06/30/2017

DCA 1, LP

Notice of Occupancy Rights under the Violence Against Women Act 1

To all Tenants and Applicants

The Violence Against Women Act (VAWA) provides protections for victims of domestic

violence, dating violence, sexual assault, or stalking. VAWA protections are not only available

to women, but are available equally to all individuals regardless of sex, gender identity, or sexual

orientation. 2 The U.S. Department of Housing and Urban Development (HUD) is the Federal

agency that oversees that DCA 1, LP is in compliance with VAWA. This notice explains your

rights under VAWA. A HUD-approved certification form is attached to this notice. You can fill

out this form to show that you are or have been a victim of domestic violence, dating violence,

sexual assault, or stalking, and that you wish to use your rights under VAWA.”

Protections for Applicants

If you otherwise qualify for assistance/tenancy, you cannot be denied admission or denied

assistance because you are or have been a victim of domestic violence, dating violence, sexual

assault, or stalking.

Protections for Tenants

If you are tenant and/or receiving assistance, you may not be denied assistance, terminated from

participation, or be evicted from your rental housing because you are or have been a victim of
domestic violence, dating violence, sexual assault, or stalking.

1
Despite the name of this law, VAWA protection is available regardless of sex, gender identity, or sexual
orientation.
2
Housing providers cannot discriminate on the basis of any protected characteristic, including race, color, national
origin, religion, sex, familial status, disability, or age. HUD-assisted and HUD-insured housing must be made
available to all otherwise eligible individuals regardless of actual or perceived sexual orientation, gender identity, or
marital status.
Form HUD-5380
(06/2017)
 2

Also, if you or an affiliated individual of yours is or has been the victim of domestic violence,

dating violence, sexual assault, or stalking by a member of your household or any guest, you

may not be denied rental assistance or occupancy rights solely on the basis of criminal activity

directly relating to that domestic violence, dating violence, sexual assault, or stalking.

Affiliated individual means your spouse, parent, brother, sister, or child, or a person to whom

you stand in the place of a parent or guardian (for example, the affiliated individual is in your

care, custody, or control); or any individual, tenant, or lawful occupant living in your household.

Removing the Abuser or Perpetrator from the Household

Site staff may divide (bifurcate) your lease in order to evict the individual or terminate the

assistance of the individual who has engaged in criminal activity (the abuser or perpetrator)

directly relating to domestic violence, dating violence, sexual assault, or stalking.

If site staff chooses to remove the abuser or perpetrator, site staff may not take away the rights of

eligible tenants to the unit or otherwise punish the remaining tenants. If the evicted abuser or

perpetrator was the sole tenant to have established eligibility for assistance under the program,

site staff must allow the tenant who is or has been a victim and other household members to

remain in the unit for a period of time, in order to establish eligibility under the program or under

another HUD housing program covered by VAWA, or, find alternative housing.

In removing the abuser or perpetrator from the household, site staff must follow Federal, State,

and local eviction procedures. In order to divide a lease, site staff may, but is not required to, ask

you for documentation or certification of the incidences of domestic violence, dating violence,

sexual assault, or stalking.

Moving to Another Unit

Form HUD-5380
(06/2017)
 3

Upon your request, site staff may permit you to move to another unit, subject to the availability

of other units, and still keep your assistance. In order to approve a request, site staff may ask you

to provide documentation that you are requesting to move because of an incidence of domestic

violence, dating violence, sexual assault, or stalking. If the request is a request for emergency

transfer, the housing provider may ask you to submit a written request or fill out a form where

you certify that you meet the criteria for an emergency transfer under VAWA. The criteria are:

(1) You are a victim of domestic violence, dating violence, sexual assault, or

stalking. If your housing provider does not already have documentation that you

are a victim of domestic violence, dating violence, sexual assault, or stalking, your

housing provider may ask you for such documentation, as described in the

documentation section below.

(2) You expressly request the emergency transfer. Your housing provider may

choose to require that you submit a form, or may accept another written or oral

request.

(3) You reasonably believe you are threatened with imminent harm from

further violence if you remain in your current unit. This means you have a

reason to fear that if you do not receive a transfer you would suffer violence in the

very near future.

OR

You are a victim of sexual assault and the assault occurred on the premises

during the 90-calendar-day period before you request a transfer. If you are a

victim of sexual assault, then in addition to qualifying for an emergency transfer

because you reasonably believe you are threatened with imminent harm from

further violence if you remain in your unit, you may qualify for an emergency

Form HUD-5380
(06/2017)
 4

transfer if the sexual assault occurred on the premises of the property from which

you are seeking your transfer, and that assault happened within the 90-calendar-day

period before you expressly request the transfer.

Site staff will keep confidential requests for emergency transfers by victims of domestic

violence, dating violence, sexual assault, or stalking, and the location of any move by such

victims and their families.

The site’s emergency transfer plan provides further information on emergency transfers, and the

Site staff must make a copy of its emergency transfer plan available to you if you ask to see it.

Documenting You Are or Have Been a Victim of Domestic Violence, Dating Violence,

Sexual Assault or Stalking

Site staff can, but is not required to, ask you to provide documentation to “certify” that you are or

have been a victim of domestic violence, dating violence, sexual assault, or stalking. Such

request from site staff must be in writing, and site staff must give you at least 14 business days

(Saturdays, Sundays, and Federal holidays do not count) from the day you receive the request to

provide the documentation. Site staff may, but does not have to, extend the deadline for the

submission of documentation upon your request.

You can provide one of the following to site staff as documentation. It is your choice which of

the following to submit if site staff asks you to provide documentation that you are or have been

a victim of domestic violence, dating violence, sexual assault, or stalking.

• A complete HUD-approved certification form given to you by site staff with this notice,

that documents an incident of domestic violence, dating violence, sexual assault, or

stalking. The form will ask for your name, the date, time, and location of the incident of

Form HUD-5380
(06/2017)
 5

domestic violence, dating violence, sexual assault, or stalking, and a description of the

incident. The certification form provides for including the name of the abuser or

perpetrator if the name of the abuser or perpetrator is known and is safe to provide.

• A record of a Federal, State, tribal, territorial, or local law enforcement agency, court, or

administrative agency that documents the incident of domestic violence, dating violence,

sexual assault, or stalking. Examples of such records include police reports, protective

orders, and restraining orders, among others.

• A statement, which you must sign, along with the signature of an employee, agent, or

volunteer of a victim service provider, an attorney, a medical professional or a mental

health professional (collectively, “professional”) from whom you sought assistance in

addressing domestic violence, dating violence, sexual assault, or stalking, or the effects of

abuse, and with the professional selected by you attesting under penalty of perjury that he

or she believes that the incident or incidents of domestic violence, dating violence, sexual

assault, or stalking are grounds for protection.

• Any other statement or evidence that site staff has agreed to accept.

If you fail or refuse to provide one of these documents within the 14 business days, site staff

does not have to provide you with the protections contained in this notice.

If site staff receives conflicting evidence that an incident of domestic violence, dating violence,

sexual assault, or stalking has been committed (such as certification forms from two or more

members of a household each claiming to be a victim and naming one or more of the other

petitioning household members as the abuser or perpetrator), site staff has the right to request

that you provide third-party documentation within thirty 30 calendar days in order to resolve the

Form HUD-5380
(06/2017)
 6

conflict. If you fail or refuse to provide third-party documentation where there is conflicting

evidence, site staff does not have to provide you with the protections contained in this notice.

Confidentiality

Site staff must keep confidential any information you provide related to the exercise of your

rights under VAWA, including the fact that you are exercising your rights under VAWA.

Site staff must not allow any individual administering assistance or other services on behalf of

site staff (for example, employees and contractors) to have access to confidential information

unless for reasons that specifically call for these individuals to have access to this information

under applicable Federal, State, or local law.

Site staff must not enter your information into any shared database or disclose your information

to any other entity or individual. Site staff, however, may disclose the information provided if:

• You give written permission to site staff to release the information on a time limited

basis.

• Site staff needs to use the information in an eviction or termination proceeding, such as to

evict your abuser or perpetrator or terminate your abuser or perpetrator from assistance

under this program.

• A law requires site staff or your landlord to release the information.

VAWA does not limit site staff’s duty to honor court orders about access to or control of the

property. This includes orders issued to protect a victim and orders dividing property among

household members in cases where a family breaks up.

Reasons a Tenant Eligible for Occupancy Rights under VAWA May Be Evicted or

Assistance May Be Terminated

Form HUD-5380
(06/2017)
 7

You can be evicted and your assistance can be terminated for serious or repeated lease violations

that are not related to domestic violence, dating violence, sexual assault, or stalking committed

against you. However, site staff cannot hold tenants who have been victims of domestic

violence, dating violence, sexual assault, or stalking to a more demanding set of rules than it

applies to tenants who have not been victims of domestic violence, dating violence, sexual

assault, or stalking.

The protections described in this notice might not apply, and you could be evicted and your

assistance terminated, if site staff can demonstrate that not evicting you or terminating your

assistance would present a real physical danger that:

1) Would occur within an immediate time frame, and

2) Could result in death or serious bodily harm to other tenants or those who work on the

property.

If site staff can demonstrate the above, site staff should only terminate your assistance or evict

you if there are no other actions that could be taken to reduce or eliminate the threat.

Other Laws

VAWA does not replace any Federal, State, or local law that provides greater protection for

victims of domestic violence, dating violence, sexual assault, or stalking. You may be entitled to

additional housing protections for victims of domestic violence, dating violence, sexual assault,

or stalking under other Federal laws, as well as under State and local laws.

Non-Compliance with The Requirements of This Notice

You may report a covered housing provider’s violations of these rights and seek additional

assistance, if needed, by contacting or filing a complaint with the local HUD field office.

Form HUD-5380
(06/2017)
 8

For Additional Information

You may view a copy of HUD’s final VAWA rule at

https://www.federalregister.gov/documents/2016/11/16/2016-25888/violence-against-women-

reauthorization-act-of-2013-implementation-in-hud-housing-programs.

Additionally, site staff must make a copy of HUD’s VAWA regulations available to you if you

ask to see them.

For questions regarding VAWA, please contact the Property Manager.

For help regarding an abusive relationship, you may call the National Domestic Violence Hotline

at 1-800-799-7233 or, for persons with hearing impairments, 1-800-787-3224 (TTY).

For tenants who are or have been victims of stalking seeking help may visit the National Center

for Victims of Crime’s Stalking Resource Center at https://www.victimsofcrime.org/our-

programs/stalking-resource-center.

For help regarding sexual assault, you may contact local law enforcement and/or social service

organizations.

Victims of stalking seeking help may contact local law enforcement and/or social service

organizations.

Attachment: Certification form HUD-91067/5382.

Form HUD-5380
(06/2017)
 OMB Control # 2502-0581
Exp. (02/28/2019)
Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants

SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING

This form is to be provided to each applicant for federally assisted housing

Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing,
the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other
organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any
issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update,
remove, or change the information you provide on this form at any time. You are not required to provide this contact information,
but if you choose to do so, please include the relevant information on this form.

Applicant Name:
Mailing Address:

Telephone No: Cell Phone No:

Name of Additional Contact Person or Organization:

Address:

Telephone No: Cell Phone No:

E-Mail Address (if applicable):

Relationship to Applicant:
Reason for Contact: (Check all that apply)
Emergency Assist with Recertification Process
Unable to contact you Change in lease terms
Termination of rental assistance Change in house rules
Eviction from unit Other: ______________________________
Late payment of rent
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.

Check this box if you choose not to provide the contact information.

Signature of Applicant Date

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.
Form HUD- 92006 (05/09)