APPLICANT/TENANT CERTIFICATION

ATTACHMENT TO HUD 50058

I/We certify that the information given to the Seminole County Housing Authority on household composition, income, net family assets, allowances, and deductions is accurate and complete to the best of my /our knowledge/belief. I/We understand that I have ten (10) business days in which to report, in writing, and on the appropriate SCHA change /request form, any changes that may occur in my household income and/or composition. The change must be brought into the office. Facsimile (fax) and phone messages are unacceptable forms of reporting. Any changes reported on or before the 15th of the month will be effective for the next month. Any changes reported after the 15th of the month will be effective for the first of the month following 30 days from the report date.

I/We understand that false statements or the giving of false information is punishable under Federal law. I/We also understand that false statements or information are grounds for termination of housing assistance and termination of tenancy.

(Your signature on this form verifies that you have read and understand the above statements.*)

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Signature of Head of Household Date

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Signature of Spouse/Co-Head Date

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Signature of other adult member Date

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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.