Application For Luther House Apartment Template Page 7
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14The following document titled “Tenant Declaration Format” is required by the U.S.
Department of Housing and Urban Development (HUD). If you are a United States
citizen, or a “national” of the United States, you only need to complete the
highlighted portions. If you are not a citizen or “national” of the United States, you
must complete the rest of the form. Please return this form with your application.
TENANT DECLARATION FORMAT
INSTRUCTIONS: Complete this format for each member of the household listed on
the Family Summary Sheet. You may copy the following forms for the second occupant
to complete.
LAST NAME: ___________________________________________________________
FIRST NAME: _____________________________ MIDDLE NAME: _____________
RELATIONSHIP TO
DATE OF
HEAD OF HOUSEHOLD: __________________ SEX:__________ BIRTH: _________
SOCIAL
ALIEN
SECURITY # _____________________________ REGISTRATION # ______________
ADMISSION # ____________________________ if applicable (this is an 11-digit
number found on INS Form I-94, Departure Record)
NATIONALITY: __________________________ (Enter the foreign nation or country
to which you owe legal allegiance. This is normally, but not always, the country of
birth.)
SAVE VERIFICATION # __________________________________________________
(to be entered by owner if and when received)
INSTRUCTIONS: Complete the Declaration below by printing or typing the
person’s first name, middle initial and last name in the space provided. Then,
review the blocks designated below and complete either Block Number 1, 2, or 3
DECLARATION:
I, ____________________________________________ hereby declare, under penalty
(print or type first name, middle initial, last name)
of perjury, that I am:
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