USDA/HUD HOUSING APPLICATION
I/We understand that the above information is being collected to determine my/our eligibility for residency.
I/We authorize the owner/management to verify all information provided on this application and my/our
signature is our consent to obtain such verification. I/We certify that all information and answers to the above
questions are true and complete to the best of my knowledge. I/We consent to the release of the necessary
information to determine my eligibility.
I/We authorize any person, or credit checking agency having any information on me/us to release any and all
such information to the owner/management or their agents or credit checking agents. I/we understand that
the credit report (rental history, arrest and/or conviction records, and retail credit history) will be done
through a credit bureau contracted with the apartment community. I/we understand that a check will be
made of the sex offender registry in states in which I/we have resided.
WARNING: “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.
USDA/HUD, the PHA and any owner (or any employee of USDA/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 the verification forms is restricted to the purposes cited thereon.
Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses
concerning an application 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 dangers,
and seek other relief, as may be appropriate, against the officer or employee of USDA/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. 208 (f), (g) and (h). Violation of these
provisions are cited as violations of 42 U.S.C. 408 f, g, and h.”
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program
Discrimination Complaint Form, found online at , or
at any USDA office, or call (866) 632‐9992 to request the form. You may also write a letter containing all of
the information requested in the form. Send your completed complaint form or letter to us by mail at U.S.
Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington,
D.C. 20250‐9410, by fax (202) 690‐7442 or email at program.intake@usda.gov
SIGNATURES: (All adult household members must sign below.)
_______________________________________________
____/_____/_____
Applicant Date
_______________________________________________
____/_____/_____
Additional Household Applicant Date
_____________________________________________
____/_____/_____
Agent for Owner Date
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