Child Support Self Certification Form
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1ALIMONY / CHILD SUPPORT SELF CERTIFICATION
Applicant’s Name
Social Security #
Address
City
State
Zip Code
I hereby certify that I receive $_______________________ per __________________(week, month, year) for the support
of:
Name(s)
Address
City
State
Zip Code
Signature:
Date:
Print your name:
Tel. #:
Relationship:
Address
•
This form is to be used only if third party verification has been attempted, but cannot be obtained.
•
This form is not required (nor is any other alimony/child support verification) if tenant states on their application
that there is no court order and support is not received or expected to be received.
PENALTIES FOR MISUSING THIS CONTENT: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and
willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD
or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use
of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willingly
requests, obtains, or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and
fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages and
seek other relief, as may be appropriate, against the officer or employee of HUD or the owner responsible for the unauthorized disclosure or
improper use. Penalty provisions for misusing the social security number are contained in the Social Security act at 208 (a) (6), (7) and (8).
Violations of these provisions are cited as violations of 42 USC 408 (a), (6), (7) and (8).
Alimony / Child Support Self Certification
MN Housing 1/13
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