____________________________________________ ________________
Signature of Head of Household Date
___________________________________________ ________________
Signature of Spouse/Co-Head Date
____________________________________________ ________________
Signature of other adult member Date
____________________________________________ ________________
Signature of other adult member Date
If you believe you have been discriminated against, you may call the Fair Housing and Equal Opportunity National Toll-free
Hot Line at 1/800-424-8590.
After verification by this Housing Agency, this information will be submitted to the Department of Housing and Urban Development
on a form HUD-50058 (Tenant Date Summary), by a computer-generated facsimile or on a magnetic tape. See the Federal Privacy
Act Statement for more information about its use.