Live In Aide Self Affidavit Form

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LIVE IN AIDE SELF AFFIDAVIT
Applicant/Tenant Name: ________________________________
Unit #: _________
This form is to be completed by the live-in attendant or, if applicable, the agency that the attendant is
employed by. Property manager is also required to obtain medical verification that the tenant requires
a live in aide.
I, ______________________________________________, certify that I am the live-in care attendant
for: ________________________________________________
The person you are caring for has applied to live in an apartment that is governed by the Federal Low
Income Housing Tax Credit Program. This program requires us to verify your live-in attendant status
prior to granting eligibility to the applicant. To be qualified as a live-in attendant, you must attest to the
following statements. By signing this form, you indicate agreement with these statements.
[ ] I am not responsible for the financial support of said person.
[ ] Said person is not responsible for my financial support (I have income of my own)
[ ] I would not otherwise be living in this unit except to provide the necessary support and care
to all said person to live independently.
[ ] I understand that I have no survivorship rights to this unit and that if said person moves-out,
for any reason, I must immediately vacate the apartment as well. I understand that the Housing
Credit Program governs this unit and that the occupants of such a unit must meet all eligibility
requirements of this program. I understand that I have not been certified as such and that my
only reason for living in the unit is to provide supportive care to said person.
Additional Comments: _______________________________________________________________
__________________________________________________________________________________
I certify under penalties of perjury that the information given above is true and complete to the best of
my knowledge. I understand that proving false or misleading information is a breach of my lease and
may be subject to criminal penalties.
Signature of Applicant/Resident: ______________________________________________
Signature of Live-In Attendant:
______________________________________________
Date:
______________________________________________
Spectrum Enterprises 2013

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