Supplement To Application For Federally Assisted Housing Template Page 9
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10Consent for Criminal Background Check
MUST Be Completed By ALL Household Members Age 18 or Older
HUD regulations require all PHAs to obtain criminal background and sex offender registration information about all adult
household members applying for housing assistance. To enable the Bloomington Housing Authority (BHA) to do this, all
household members age 18 or older MUST answer the questions below and sign to consent to a background check.
The BHA will deny the application that does not provide complete and accurate information or does not consent to a
background check. Please answer ALL the following questions:
1) Have you been terminated from a federally assisted site within the past five years? Yes No
2) Do you currently use illegal drugs or abuse alcohol? Yes No
3) Are you currently subject under a state sex offender registration program? Yes No
4) Have you ever been convicted of a drug-related crime? Yes No
5) Have you been convicted of a crime within the past 5 years? Yes No
6) Are you currently charged with any of the above criminal activities? Yes No
7) Have you been released from jail within the past five (5) years? Yes No
If yes please list the reason(s) _______________________________________________________________________
8) Are you or any household member now charged with an unresolved crime which has not yet resulted in a plea of guilty,
a court trial, or the dropping of charges? Yes No
9) Please list all states in which you have lived or have held licenses to drive
________________________________________________________________________________________________
10) Have you ever used or been known by any other name?
Yes No
If yes, please list all names used:
__________________________________________________________________________________________________
I understand the above information is required to determine eligibility for assistance. I certify my answers are true and
complete to the best of my knowledge. I understand making false statements is grounds for denial or termination. I
authorize the BHA to verify the above information and consent to the release of the necessary information to determine
my eligibility. I authorize the release of criminal records and/or sex offender registration information to the BHA
or agencies contracted by the BHA to conduct criminal background checks.
Today’s Date
Applicant’s (or Other Adult Member’s) Full Name (Please Print)
Social Security Number
Date of Birth
Applicant’s (or Other Adult Member’s) Signature
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