Eden, Inc. Housing Application Form (Page 6 of 7) in pdf

(1) Self-care,

(2) Receptive and expressive language,

(3) Learning,

(4) Mobility,

(5) Self-direction,

(6) Capacity for independent living, and

(7) Economic self-sufficiency; and

e. Reflects the person's need for a combination and sequence of special,

interdisciplinary, or generic care, treatment, or other services that are of

lifelong or extended duration and are individually planned and coordinated

3. ___YES ___NO

Is a person with a chronic mental illness, i.e., he or she has a severe and persistent mental

or emotional impairment that seriously limits his or her ability to live independently, and

whose impairment could be improved by

4. ___YES ___NO

Is a person whose sole impairment is alcoholism or drug addiction.

____________________________

_______________________________

NAME AND TITLE OF PERSON

FIRM/ORGANIZATION

SUPPLYING THE INFORMATION

____________________________

________________________________

SIGNATURE

DATE

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

RELEASE:

I hereby authorize the release of the requested information. Information obtained under this consent

is limited to information that is no older than 12 months. There are circumstances that would require the owner to

verify information that is up to 5 years old, which would be authorized by me on a separate consent attached to a

copy of this consent.

Signature

Date

Note to Applicant/Tenant:

You do not have to sign this form if either the requesting organization or the

organization supplying the information is left blank.

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 and any owner (or any employee of HUD 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 $5,000. 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 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

208 (a) (6), (7) and (8). Violations of these provisions are cited as violations of 42 USC 408 (a) (6), (7) and (8).

HUD-90102 12/2007

Eden, Inc. Housing Application Form Page 6

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