Fillable Citizenship Declaration - Verification Consent Form printable pdf download

Citizenship Declaration - Verification Consent Form

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4350.3 REV-1

Exhibit 3-6: **Sample** Verification Consent Form

INSTRUCTIONS: Complete this format for each noncitizen family member who declared

eligible immigration status on the **Citizenship** Declaration format. If this format is being

completed on behalf of a child, it must be signed by the adult responsible for the child.

CONSENT

I, _________________________________________________ hereby consent to the following:

(print or type first name, middle initial, last name)

The use of the attached evidence to verify my eligible immigration status

to enable me to receive financial assistance for housing; and

The release of such evidence of eligible immigration status by the project

owner without responsibility for the further use or transmission of the

evidence by the entity receiving it to the following:

HUD, as required by HUD; and

The DHS for purposes of verification of the immigration status of

the individual.

NOTIFICATION TO FAMILY:

Evidence of eligible immigration status shall be released only to the DHS for purposes 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.

Signature

Date

Check here if adult signed for a child:

6/07

HUD Occupancy Handbook

Exhibit 3-6

Citizenship Declaration - Verification Consent Form

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