Pbv Application Packet - Housing Authority Of Snohomish County (Page 29 of 38) in pdf

HOUSING AUTHORITY OF SNOHOMISH COUNTY

Avenue West • Everett, Washington 98204

12711- 4

PHONE (425) 290-8499 • FAX (425) 290-5618

Section 214 of the Housing and Community Development Act of 1980, as amended, requires the Housing Authority

of Snohomish County and the Department of Housing & Urban Development (HUD) to ensure the financial

assistance is made available only to persons who are U.S. Citizens, U.S. Nationals or Non-citizens who have been

lawfully admitted to the United States and considered to have “eligible immigration status.” The law requires all

tenants for assisted housing who claim to have “eligible immigration status” to sign a consent form authorizing

HUD to verify the information supplied with the U.S. Department of Homeland Security (DHS).

Purpose: This information is required to determine your eligibility for continued housing assistance.

Use of the Information to be Obtained: The evidence you supply to document your eligibility for housing assistance

may be released by the Housing Authority, without responsibility for the further use or transmission of the evidence by the

entity receiving it, (1) HUD, as required by HUD, and (2) the DHS for the purpose of establishing eligibility for financial

assistance and not for any other purpose. HUD is not responsible for the further use or transmission of the evidence or

other information by the DHS.

Who Must Sign This Consent Form? Each non-citizen in the household who will be receiving housing assistance

and claims “eligible immigration status” must sign below. Adults, age 18 years or older, must sign for themselves.

In the case of minor children (under 18 years old), the form must be signed by the head of household and/or adult

member who is responsible for each minor child.

Failure to Sign the Consent Form: Your failure to sign the consent form may result in the denial of eligibility or

termination of assisted housing (subsidy) benefits, or both. Denial of eligibility or termination of benefits (subsidy)

is subject to the Housing Authority’s grievance procedures or Section 8’s informal hearing process, whichever is

applicable.

Consent: I authorize HUD to request and obtain verification from the DHS of the information I have supplied

regarding my immigration status. I understand that this information is true and accurate to the best of my

knowledge.

Head of Household

Date

Spouse/Co-Tenant

Date

Other Adult (over age 18)

Date

Other Adult (over age 18)

Date

Consent for Minor Children: I certify that I am the head of household and/or the adult family member responsible

for the minor children listed below. I authorize HUD to request and obtain verification from the DHS of the

information supplied regarding their immigration status. I understand this information is needed to determine

eligibility for housing assistance (Federal subsidy); and I certify that the information I have supplied is true and

correct to the best of my knowledge. List minor children:

Signature

Date

Parent or Guardian

Equal Housing Opportunity

Pbv Application Packet - Housing Authority Of Snohomish County Page 29