rP Kr

MANAG EM ENT

o Using blue ink, please print answers to all questions on the application truthfully and cornpletely.

o Do not leave any questions blank even if the questions do not apply to you or your household.
Enter "11one" or "N/A" for those questions.

r It is irnportant to remember that falsification, or incomplete inforrnation provided by you and your
household members is grounds for automatic rejection.

t Applications will not be considered unless they are filled out completely and correctly.

o CornPleting the application during an application appointment can help ensure that you housing
application is completed accurately and tirnely and therefore will help expedite your housing.
However, applications are allowed to be completed off-site by request.

o ALL signatures must be original, dated on the same date, and signed in front of the office staff.
As a reasonable accolruxodation, applications can be mailed in, but signatures must be notarized
and at least one in-person rneeting with all household members present is required.

o Disclosure of Social Security Nurnbers for all non-exempt persons anticipated to live in the
aparlment home is required.

o If the application is not filled out completely, it may be denied. Incornplete applications will be
returned to the applicant for completion and will delay placement on the waitlist for housing.

o Please also bring a copy of your proof of social security number, proof of birth, and State or Federal
issued picture I.D. (i.e., identification card, driver license, etc.), or attach copies if the application
is mailed in.

Thank you for your interest in PK Managernent, LLC Rental Housing!

E?T"#,',,yfiiTE

Equal Housing Opportunity. Landlord makes this housing available without regard to race, color, religion, sex, National origin, familial status,
disability (handicap), military status, sexual orientation, gender identity or ancestry. PK Management, LLC does not discriminate on the basis of
status in the admission or access to, or treatment or employment in, its federally assisted programs and activities. The person named
below has been designated to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and
Development's regulations implementing Section 504 (24 CFR, part 8 dated June 2, '1988)and is the one who evaluates any reasonable
accommodation or modification requests that have been submitted. National Director of Training and Compliance, 26301 Curtiss Wright Parkway
Suite 300, Richmond Hts., OH 44143, 216-472-1870 x 1 14 (TTY 7-1-1).
 How did you hear about us? (Check all that apply)
O_lnternet E watr-in
D Newspaper E Brochure/Flyer
E Referred by Resident tr pho;; Book
LJ Referred by Other ! Magazine Ad
MANAG

APPLICATION FOR HOUSING

:ll:jllill,"l;.9ii::::YtlYg:11"-.j1 IIly:ll9:T"11 LLC ioes not discriminate on to"ii. oi JiJ"iirity or rederar, state or rocar protecred
:.",:1X1'
in the admission or access to, or treatment or emptoyme-nt in, its federary ,..i.t"0 p,ogo;i;;;;itd
" H,;ffi#ffi|fi:iili:.'##"r1$Hff1"
't"t$
whoi':.,:,,:p,j!1.":,Y:,l"tl:"1?:1Y,:::jl:ll^"1yi:ITl:...o1!lil"9 i! IUP,''
evaluates anv reasonable accommodation or modification requests
resuratibns-impremenrins s""rr. soiiz+ cFR, part 8 dared June 2,1eBB) and is the
'[Link],'t1";;i;;;;i";;;
lht Parkway, Ste.300, Richmond j
Hts., OH 44143, 216-472-jB7O x 14
tnat navioeen rroriii",i.- riJni,iil,[Link],[][Link];ffi'3lll,i',
FOR OFFICE USE ONLY

Type of Picture lD Veified Expiration Date

PLEASE COMPLETE ALL QUESTIONS IN BLUE lNK USING N/A IF SOMETHING DOESN'T APPLY
Indicatebedroomsize(s)yourhousetroIowiIt
Occupancy Standar 's maximum per Uecirb6m:
LJ Druqro IJ lEedroom tr 2Bedroom tr 3Bedroom tr 4Bedroom
Doyouoramemberofyourhouseholdrequireaspecificac
lf yes, please check allapplicable: tr Mobility: Feature Details; E Vision E Hearing

HOUSEHOLD INFORM TION

List all household members that are apptying to live in this apartment with you, (include yourselq.
Relation Age of
Name To head Social Security Date of Birth
(First, Middle lnitial, Last) Number* Month, Date, Year Member

Current Mailing Address

City, State, Zip Code

PrimaryPhone lt ) 2nd Phone/Emaitl ( )

*Did anyone not disclose

a social security number due to the fact that tney do not contend eligible immigration status or they were
52 years of age or older and starting receiving subsidy as of 1/31/102
f Ves ! ruo lf yes, who?
YES NO

1.
Are you seeking housing due to (Check all that apply):
EI f] n Government Action n Natural Disaster n Presidentially Declared Disaster
Revised 21 1 122 Applicalion Page 1 of 8
 /ES I

trE, Name
any additions
Relationship
Explanation

tl Es nre tIrEr(i aily duntiilt fleusenolq memDers wno unoer normal conditions would live
(For example, a,spouse awav in the militarv or children awav at college.)
with you?

Explanation

tr E+. I
empers (rNULUurNs MTNoRS)currenfly a citizen of the
pleaseexplain. Note: This does not automaticallv exclrrcl" r.,, i. hnrreohntrt frnm United statesz tt No,
atiairririrr,
Househotd Member(s)
Explanation

trftr s.
a.e ,vs vr arry .,rrrtrt a(rur*ousenorq memDgrs (cnecK all that apply):
ECurrently enrolled in an institute of higher learning, eittrer ruil-iime or part-time, or
[Link] to be enrolled in an institute oi nlgner leariiint in the next 12 months, or
ElHave been a student in an institute of hig-her learning-in the past 12 months?
Household Member(s)
Explanation

trE, Are there any household mqmbers under ttre age

Household Member(s)
Explanation

tr Er. Do you have full custody of your chi

Explanation

tr fX'. Do you currently pay child care for any of your child(ren)?
Household Member Care Provider Amount

tr E'. Are you or a member of your household disabled -- have a physicat or mental impairment that
substantially limits one or more major life activities? !f yes, rirtro

I Eto. Will you or any ADULT household member require a live-in care attendant due to disability or .g"?
Name of Attendant
Relationship (it any)

tr f1,,. Does your household have or anticipate having any pets?

This question is applicable only at senior/disabled ploperties. All other property types have a strict no pet policy.

tr fF2 Does your household have or anticipate needi

disability? lf yes, explain

tr f,, Are you a veteran?

Branch and discharge date
14. lf the head, spouse or cohead is 62 years of age

rT
Entr
of the following unreimbursed medicat or disability expenses?
Medical premiums?
Doctor, dentist, or hospital bills?

iltr
nn
Prescription bills?
Bills for eyeglasses?

DfI Amounts for medical equipment?

trtr Care expenses for a disabled or elderly member?

Etr Medical mileage?

Revised 21 1 122 Application Page 2 of 8

 tr f['. Does any member receive grants or scholarships?
lf yes, for what institution?

tr ffs. Are you, or any perspective member currently enrolled in a drug or alcohol rehabilitation
program?
!f yes, where?

beginning with
current residency first. p if ti ora
tor every monft in tne I . Attach extra sheet if necessary
HOUSING HISTORY
Land lord/Owner's Name/Address Your Address Own/Rent Dates
1. Name From
own tr
Rent tr
Address To

Comments:

Phone #

2. Name
own tr From

Address
Rent tr To

Comments:

Phone #

3. Name
own tr From

Address
Rent tr To

Comments:

Phone #

EMERGENCY CONTACT
List someone in the area that is not already on the application.
Name Relationship
Address
Phone # Email/phone Years Known
VEHICLE IDENTIFICATION
List vehicle information for all vehicles that are owned or operated by any household member.
Tag / License Plate # State lssued Make / Model / Year / Color
Vehicle #1
Vehicle #2

17. Please list ALL states in which you and each member have Iived.

Revised2l1l22 Application Page 3 of 8

RENTAL HISTORY
YES NO
you or anyone ni
U Ur'. I unit of any type an apartment, home, mobile home or trailer?
ixplanation
\re you or anyone named on this application currently living in a subsidized rental unit? lf yes, please
U E,,. lxplain where.

lVhere

U Uro. or anyone named on this application ever left property owing money?
=xplanation

U Ur'. you or anyone in the household have a voucher from Housing Authority or have applied for one?

=xplanation

INCOME INFORMATION
lncome is counted for any household member 18 years or older and/or legally emancipated. However,
if the income is unearned income such as a grant or benefit, it may or may not be counted as
household income.
lnclude all income rollgipAledlfor the next 12 months.
Do YOU or ANYONE in your household receive OR expect to receive income from:
YES NO
re you or any other ADULT household members claiming zero income?
E Err. {ousehold Member
ixplanation

EI 8,, mployment wages or salaries? (lnclude overtime, tips, bonuses, commissions and payments

l{orrsehold Memher Name of Comnanv GROSS Amounf

U Elro. overtime
Household Member
commissions and pavments received in cash.
Tvoe of Business NET Amount

lJ Er'. ular and Hazardous Duty pay as a member of the Armed Forces/Military?
Household Member Base Name & Branch GROSS Amount

E Ert. U nem ployment benefits o r workma n's com pe nsation ?

Household Member I CnOSS Amount

fl 8,, Assistance, General Relief, AFDC or Temporary Assistance for Needy Fanfrilies (TANF)?
Household Member I GROSS Amount

QanticaA )l'l l)) Annlinalinn Daaa A al Q

 YES NO

E Ert. (a) childsupportorAlimony?([Link]

unless lega! action has been taken to remedy. We must also count support that is not court-
ordered rather received directly from payer.)
Household Member Payer GROSS Amount Rcvd

(b) How is the support received? (Check altthat apply)

n Child Support Enforcement Agency Name of Agency

tr Court of Law Name of Court

tr Directly from lndividual Name of Person

D Other: Explanation

trf (c) lf supporUalimony is court-ordered but not actually received, are you taking legat action to
remedy?
Explanation

I EIrr. Social Security, SSI or any other payments from the Social Security Administration?
Household Member GROSS Amount

E Ero. Regular payments from a Veteran's benefit, pension, retirement benefit or annuity,
Household Member Source of Benefit GROSS Amt

31. Do YOU or ANYONE in your household have regular payments from any of the following? Check all
that apply and explain below.

ntr Severance package

trfl
trtr
Any type of settlement (For example, insurance settlements)
Lottery winnings

utr lnheritances

frn Renta! property or other types of real estate transactions

trtr Gifts or payments from anyone outside of the household (This includes anyone giving you
money or payinq any of vour expenses - even if they pay it directly to the company.)

trtr Any other income sources or types not listed

Household Member Source of Benefit Amount

Do you or any other household members expect any changes to your income in the next 12 months ..
N EI" including applying or having applied for income or benefits?
Explanation

Revised211l22 Application Page 5 of 8

 ASSET INFORMATION
lnclude all assets held and the income derived from the asset. tNcLUoe nu- nssers HELD By
ALL HOUSEHOLD MEMBERS INCLUDING MINORS. Do YOU or ANYONE in your househotd
YES NO
CHECKING (C), SAVINGS (S) and/or MONEY MARKET (M) account(s)? List AMOUNT & INTEREST RATE
EI Er,.
Household Member Type L|SLFinancial Institution
clsEMn'
CEStrMtr
cnsEMtr
c!strMtr
34. Do YOU or ANYONE in your household have any of the following? Check all that aoply and e-olain
below AND LIST AMOUNT AND TTVfEREST OR DIVIDETVDS if applicable
trtr Cash on hand that is held for investment purposes AMOUNT:

ntr Certificate of Deposit (CDs), money market accounts or treasury bills AMOUNT:_INTEREST:_
Ttr Trust Fund(s) AMOUNT: INTEREST:

trtr Pensions,!RAs,Keogh,401(ky403(b)orotherretirementaccountAMoUNT:-lNTEREST:
trtr Whole Iife insurance policy CASH VALUE: DIVIDENDS:

trT Any asset held within a safe deposit box AMOUNT:

trtr Stocks, bonds or securities AMOUNT: INTEREST:

trtr Real estate, rental property, land contracts/contract for deeds or other real estate holdings (This
includes your personal residence, mobile homes, vacant land, mineral rights, vacation homes or
commercialproperty) CASHVALUE: INCOME FROM RENTAL

trtr Personal property held as an investment? (This includes coin or stamp collections, spoon or
baseball card collections, artwork, or show cars and antiques. This does not include your
persona! belongings such as your car, furniture or clothing.) CASH VALUE:
Ttr DirectExpress,otherBenefitCards,PayCardsorcashaps(Chime/Venmo/ApplePay/etc)AMoUNT:-

trtr GoFundMe/Crowdsourcing or cryptocurrency/bitcoin AMOUNT:

trtr Lump Sum Receipts (lottery winnings, inheritance, etc.) AMOUNT:

trtr Any others not listed? List AMOUNT AND INTEREST RATE
Household Member Financi

Have you or any other household members disposed of or given away any asset(s) for LESS than fair
trff' market value within the past 2 years?
Household Member
Date and Explanation

Revised 211 122 Application Page 6 of 8

COMPLIANCE !NFORMATION
lnclude info rmation for any of the circumstances below for any household member. Please note
that saying yes in this category is not an automatic denia! but is used to determine if the
screening c riteria is met in tandem with information found on credit and criminal screening.
YES NO lf yes, please explain
Are you, or any prospective household member currently engaged in the use of illegal drugs or a
I ngs. controlled substance including marijuana?
Explanation

Have you, or any prospective household member, ever used any name(s) or social security numbers
I [gz. other than the one currentlv beinq used?
Explanation

Have you or any other perspective adult members of your household ever committed any fraud in a
E Egs. federally assisted housing program or been requested to repay money for not reporting or
misrepresenti n g i nformation for such housin g/prog rams?

Explanation

Have you, or any perspective member, ever been evicted from Federally assisted housing for drug
E nsg. related criminal activitv?
Explanation

Have you or anyone named on this application left owing a previous landlord money? lf yes are
E Eao. currentlv makinq pavments on amounts due? Yes No
Explanation

n nqr. Are YOU or ANY of your household members applying for housing currently on parole or probation?
Name of Probation Officer & Gontact information:

Explanation

42. Have YOU oTANYONE named on this application ENGAGED lN OR BEEN CONVICTED OF any of the
followins? Explain below.
ntr A felony?

trtr Any illegal drug activity?

trn A pattern of alcohol or drug abuse that interferes with the health, safety or right to peaceful enjoyment
of the premises by others?

utr
nn
Any crimes of physical violence to persons or property or any other criminal act that will affect the
health. safetv or welfare of the other residents?
A misdemeanor?
trn Property damage?
Household Member(s)
Explanation

tr E+9. Are YOU or ANY of your household members subject to a lifetime sex offender registration program
in ANY state?
Name of Household Member(s)
List State(s)
levised211l22 Application Page 7 of 8
SlGNATURE CLAUSE
PENALTIES FOR MISUSING THIS VERIFICATION FORM:
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). Violation of these
provisions are cited as violations of 42 U.S.C. Section a08 (a) (6), (7) and (8).

Credit, Criminal and Sex Offender checks will be conducted by RealPage, lnc., 4000 lnternational
Parkway, Carrolltown, Texas 75007-1 91 3.

APPLICANT CERTIFIGATION and CONSENT RELEASE AUTHORIZATION:

!/we certify that if selected to move into this project, the unit l/we occupy will be my/our only
residence. l/we understand that the above information is being collected to determine my/our
eligibility for rental assistance. l/we authorize the owner to verify all information provided on this
application and to contact previous or current landlords or other sources for credit, criminal and
sex offender and verification information which may be released to appropriate Federal, State or
local agencies. l/we certify that the statements made in this application are true and complete to
the best of my/our knowledge and belief. l/we understand that false statements or information
are punishable under Federal law and reason for rejection of my/our application. I authorize
inquiries to be made to verify the information in this application. !/we understand that my
occupancy is contingent upon meeting Management's resident selection criteria and the HUD
and/or Low lncome Tax Credit program requirements as applicable.

I hereby authorize the release of the requested information. lnformation obtained under this
consent is limited to information that is no older than 12 months. There are circumstances that
would require the owner to verify information that is up to 5 years older, which would be
authorized by me on a separate consent attached to a copy of this consent. l/we do not have to
sign the consent if it is not clear who will provide the information or who will receive the
information.

Head of Household Signature Date

Spouse/Co-Head/Other Adult Signature (if applicable) Date

Spouse/Co-Head/Other Adult Sig natu re (if appl icable) Date

Spouse/Co-Head/Other Adult Signature (if applicable) Date

l,evised 211122 Application Page 8 of 8
 U.S. Department of Housing and Urban Development

Document Package for

Applica nt's/Tenant's Gonsent
to the
Release of lnformation

This Package contains the following documents:

1. HUD-9887/A Fact Sheet describing the necessary verifications

2. Form HUD-9887 (to be signed by the Applicant or Tenant)

3. Form HUD-9887-A (to be signed by the Applicant or Tenant and Housing Owner)

4. Relevant Verifications (to be signed by the Applicant or Tenant)

Each household must receive a copy of the 9887/A Fact Sheet, form HUD-9887, and form HUD-9887-A.

Attachment to forms HUO-9887 & 9887-A (02/2007)

HUD-9887/A Fact Sheet
Verification of lnformation Provided by
Applicants and Tenants of Assisted Housing
What Verifi cation lnvolves lf an adult member of your household, due to extenuating circumstances iS
unable to sign the form HUD-9887 or the individual verilication forms on time,
To receive housing assistance, applicants and tenants who are at least 18 the O/A may document the file as to the reason for the delay and lhe specific
years of age and each family head, spouse, or co-head regardless of age plans lo obtain the proper signature as soon as possible.
must provide the owner or management agent (OiA) or public housing agency
(PHA) with certain information specified by the U.S. Department of Housing The O/A must tell you, or a third party which you choose, of the findings made
and Urban Development (HUD). as a result of the O/A verifications authorized by your consent. The O/A must
give you the opportunity to contest such findings in accordance with HUD
To make sure that the assistance is used properly, Federal laws require that Handbook 4350.3 Rev. 1. However, for information received under the form
the information you provide be verified. This information is verified in two HUD-9887 or form HUD-9887-A, HUD, the O/A, or the PHA may inform you of
ways: these findings.

O/As must keep tenant files in a location that ensure confidentiality. Any
1. HUD, O/A's and PHAS may verify the information you provide by checking employee of the O/A who fails to keep tenant information confidential is subject
with the records kept by certain public agencies (e.9., Social Security to the enforcement provisions of the State Privacy Act and is subject to
Administration (SSA), State agency that keeps wage and unemployment enforcement actions by HUD. Also, any applicant or lenant affected by
compensation claim information, and the Department of Health and Human negligent disclosure or improper use of information may bring civil action for
Services' (HHS) National Directory of New Hires (NDNH) database that stores damages, and seek other relief, as may be appropriale, against the employee.
wage, new hires, and unemployment compensation). HUD (only) may verify
information covered in your tax returns from the U.S. lnternal Revenue
Servic€ (lRS). You give your consent to the release of this information by HUD 9887/A requires the O/A to give each household a copy of the Fact
signing form HUD-9887. Only HUD, OiAs and PHAs can receive information Sheet, and forms HUD-9887, HUD-9887-A along with appropriate individual
authorized by this form. consent forms. The package you will receive will include the following
documents:

'l . HUD-9887/A Fact Sheet: Describes the requirement to verify information

2. The O/A must verify the information that is used to determine your eligibility provided by individuals who apply for housing assistance. This fact sheet also
and the amount of rent you pay. You give your consent to the release of this describes consumer protections under the verification process.
information by signing the form HUD-9887, the form HUD-9887-A, and the
individual verification and consent forms that apply to you. Federal laws limit
the kinds of information the O/A can receive about you. The amount of 2. Form HUD-9887: Allows the release of information between government
income you receive helps to determine the amount of rent you will pay. The agencies.
O/A will verify all of the sources of income that you report. There are certain 3. Form HUD-9887-A: Describes the requirement of third party verilication
allowances that reduce the income used in determining tenant rents. along with consumer protections.

Example: Mrs. Anderson is 62 years old. Her age qualifies her for a
medical allowance. Her annual income will be adjusted because of this 4. lndividual verification consents: Used to verify the relevant information
allowance. Because Mrs. Anderson's medical expenses will help determine provided by applicants/tenants to determine their eligibility and level of
the amounl of rent she pays, the O/A is required to verify any medical benefits.
expense that she reports.
Example: Mr. Harris does not qualify for the medical allowance because he Consequences for Not Signing the Consent Forms
is not at least 62 years of age and he is not handicapped or disabled.
Because he is not eligible for the medical allowance, the amount of his lf you fail to sign the form HUD-9887, the form HUD-9887-A, or the individual
medical expenses does not change the amount of rent he pays. Therefore, verification forms, lhis may result in your assistance being denied (for
the O/A cannot ask Mr. Harris anything about his medical expenses and applicants) or your assislance being terminated (for tenants). See further
cannot verify with a third party about any medical expenses he has. explanation on lhe forms HUD-9887 and 9887-A.

Customer Protections lf you are an applicant and are denied assistance for this reason, the O/A must
lnformation received by HUD is protected by the Federal Privacy Act. notify you of the reason for your rejection and give you an opportunity to
lnformation received by the O/A or the PHA is subject to State privacy laws. appeal the decision.
Employees of HUD, the O/A and the PHA are subject to penalties for using
these consent forms improperly. You do not have to sign the form HUD-9887, lf you are a tenant and your assistance is terminated for this reason, the O/A
the form HUD-9887-A or the individual verification consent forms when they must follow the procedures set out in the Lease. This includes the opportunity
are given to you at your certification or recertification interview. You may take for you to meet with the O/A.
them home with you to read or to discuss with a third party of your choice.
The O/A will give you another date when you can return to sign these forms.
Programs Covered by this Fact Sheet
Rental Assistance Program (RAP)
lf you cannot read and/or sign a consent form due to a disability, the O/A Rent Supplement
shall make a reasonable accommodation in accordance with Section 504 of Section I Housing Assistance Payments Programs (administered by
the Rehabilitation Act of 1973. Such accommodations may include home the Office of Housing)
visits when the applicant's or tenant's disability prevents him/her from coming Section 202
to the office to complete the forms; the applicant or tenant authorizing another Section 202 and 811 PRAC
person to sign on his/her behalf; and for persons with visual impairments, Section 2021162 PAC
accommodations may include providing the forms in large script or braille or
providing readers. Section 221(dX3) Below Market lnterest Rate
Section 236
HOPE 2 Home Ownership of Multifamily units

O/A must give a copv of this HUD Facl Sheet to each household. See the lnstructions on form HUD-9887-A. . , , = ,,,,= ====
ntta
 Notice and Consent for the Release of lnformation
and Urban Development
to the U.S. Department of Housing and Urban Development (HUD)
and to Office of Housing
an Owner and Management Agent (O/A), and lo a public Housing
Federal Housing Commissioner

HUD Office requesting release of informatior o/Arequestingrelea@ PHA requesting rete

(Owner should provide the full address of the HUt provide the full name and address of the Owner).
full name and address of the pHA and the tiile of the director or
Field Offjce, Attention: Director, Multifami15 administrator. lf there is no pHA Owner or pHA contract
Division): administrator for this proJect, mark an X through this entire box):

U.S. Dept. of Housing & Urban Development Festus Gardens lnvestments, LLC
St. Louis Field Office PK Management, LLC
Missouri Housing Development Commission
1222Sptuce Street, Suite 3.203 15301 Ventura Boulevard, Building B, Suite 570 920 Main Street, Suite 1400
St. Louis, MO 63103-2836 Sherman Oaks, CA 91403 Kansas City, MO 64105

Notice To Tenant: Do not sign this form if the space above organizations requesting release of information is left blank.
blank vou Oo not nave to signtnElffi
when it is given to you You may take the form home with you to read or discuss with a third party of your choice and return to
sign the consent on a date you
have worked out with the housing owner/manager.

Authority: Section 217 of the Consolidated Appropriations Act of 2004 (pub information it obtains in accordance with any applicable State privacy law.
L. 108-199). This law is found at 42 U.S.C.653(J). This taw authorizes HHS After receiving the information covered by this notice of consent, HUD, the
to disclose to the Department of Housing and Urban Development (HUD) O/A, and the PHA may inform you that your eligibility for, or level of, assistance
information in the NDNH portion of the "Location and Collection System of is uncertain and needs to be verified and nothing else.
Records" for the purposes of verifying employment and income of individuals
participating in specified programs and, after removal of personal identifiers,
HUD, O/A and PHA employees may be subject to penalties for unauthorized
to conduct analyses of the employment and income reporting of these
disclosures or improper uses of the income information that is obtained based
individuals. lnformation may be disclosed by the Secretary of HUD to a
on the consent form.
private owner, a management agent, and a contract administrator in the
administration of rental housing assistance.

Who Must Sign the Consent Form: Each member of your household who is at
Section 904 of the Stewart B. McKinney Homeless Assistance Amendments least 18 years of age and each family head, spouse, or co-head, regardless of
Act of 1988, as amended by section 903 of the Housing and Community age, must sign the consent form at the initial certification and at each
Development Act of 1992 and section 3003 of the Omnibus Budget recertification. Additional signatures must be obtained from new adult
Reconciliation Act of 1993. This law is found at 42 U.S.C.3544. This law members when they join the household or when members of the household
requires you to sign a consent form authorizing: (1) HUD and the pHA to become 18 years of age.
request wage and unemployment compensation claim information from the
state agency responsible for keeping that information; and (2) HUD, O/A, and Persons who apply for or receive assistance under the following
programs are required to sign this consent form:
the PHA responsible for determining eligibility to verifo salary and wage
information pertinent to the applicant's or participant's eligibility or level of
benefits; (3) HUD to request certain tax return information from the U.S. Rental Assistance Program (RAP)
Social Security Administration (SSA) and the U.S. lnternal Revenue Service Rent Supplement
(rRS).
Section I Housing Assistance Payments Programs (administered by the
Section 202; Sections 202 and 81 1 PRAC; Section 2021162 PAC Section
Purpose: ln signing this consent form, you are authorizing HUD, the above 221(d)(3) Below Market lnterest Rate
named O/A, and the PHA to request income information from the government Section 236
agencies listed on the form. HUD, the O/A and the PHA need this information HOPE 2 Homeownership of Multifamily Units
to verify your household's income to ensure that you are eligible for assisted
housing benefits and that these benefits are set at lhe correct level. HUD, the
O/A and the PHA may participate in computer matching programs with these
sources to verify your eligibility and level of benefits. This form also Failure to Sign Consent Form: Your failure to sign the consent form may result
authorizes HUD, the O/A and the PHA to seek wage, new hire (W-4) and in the denial of assistance or termination of assisted housing benefits. lf an
unemployment claim information from current and former employers to verify applicant is denied assistance for this reason, the owner must follow the
information obtained through computer matching. notification procedures in Handbook 4350.3 Rev. I. lf a tenant is denied
assistance for this reason, the owner or managing agent must follow the
procedures set out in the lease.
Uses of lnformation to be Obtained: HUD is required to protect the income
information it obtains in accordance with the Privacy Act of 1974, 5 U.S.C.
552a. The O/A and the PHA is also required to protect the income

Consent: I consent to allow HUD, the O/A, or the PHA to request and obtain income information from the federal and state agencies listed on the back
of this form for the purpose of verifying my eligibility and level of benefits under HUD's assisted housing programs.
Signatures: Additional Signatures, if needed:

Head of Household Date Other Family Members 18 and Over Date

Spouse Date Other Family Members 18 and Over Date

Other Family Members 18 and Over Date Other Family Members lS and Over Date

Other Family Members 18 and Over Date Other Family Members 18 and Over Date

Original is retained on file at the project site ref. Handbooks 4350.3 Rev-'1, 457'l .'l ,457112 & form HUD-9887 (0212007 )
4571 .3 and HOPE ll Notice of Program Guidelines
Agencies To Provide lntormation: 1065-K1 Panners Share ot lncome, uredtts, lJeducttons. etc.
104'l-K1 Beneficiary's Share of lncome, Credits, Deduciions, etc.
state wage lnformation collection Agencies (HUD and pHA). This consent is '1
120S-Kl Shareholder's Share of Undistributed Taxable lncome, Credits,
limited to wages and unemployment compensation you have received during
Deductions, etc.
period(s) within the last 5 years when you have received assisted
housing
benefils. I understand that income information obtained from these sources will be used
to verify information that I provide in determining initial or continued eligibility
U.S. Social Security Administration (HUD only). This consent is limited to the for assisted housing programs and the level of benefits.
wage and Self employment information from you current form W-2.
No action can be taken to terminate, deny, suspend, or reduce the assistance
your household received based on information obtained about you under this
National Directory of New Hires contained in the Department of Health and consent until the HUD Office, Office of lnspector General (OlG) or the pHA
Human Services' system of records. This consent is limited to wages and (whichever is applicable) and the O/A have independenUy verified: 1) the
unemployment compensation you have received during period(s) within 5 amount of the income, wages, or unemployment compensation involved; 2)
years when you have received assisted housing benefits. whether you actually have (or had) access to such income, wages or benefits
for your own use, and 3) the period or periods when, or with respect to which
you actually received such income, wages, or benefits. A photocopy of the
U.S. lnternal Revenue Service (HUD only). This consent is limited to signed consent may be used to request a third party to verify any information
information covered in your current tax return. received under this consent (e.9., employer).

HUD, the O/A or the PHA shall inform you, or a third party which you
This consent is limited to the following information that may appear on your designate, of the findings made on the basis of information verified under this
current tax return. consent and shall give you an opportunity to contest such findings in
accordance with Handbook 4350.3 Rev.1.
1099-5 Statement for Recipients of Proceeds from Real Estate
Transactions lf a member of the household who is required to sign the consent form is
unable to sign the form on time due to extenuating circumstances, the O/A
1099-8 Statement for Recipients of Proceeds from Real Estate may document the file as to the reason for the delay and the specific plans to
Brokers and Barters Exchange Transactions obtain the proper signature as soon as possible.

1099-4 lnformation Return for Acquisition or Abandonment of This consent forms expires 15 months after signed.
Secured Property

1099-G Statement for Recipients of Certain Government

Payments

1099-DlV Statement for Recipients of Dividends and Distributions

1099 INT Statement for Recipients of lnterest lncome

1099-MISC Statement for Recipients of Miscellaneous

lncome

't 099-OlD Statement of Recipients of Original lssue Discount

1099-PATR Statement for Recipients of Taxable Distributions

Received from Cooperatives

1099-R Statement for Recipients of Retirement Plans W2-G

Statement of Gambling Wnnings

Privacy Act Statement: The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937, as
amended (42 U.S.C. 1437 el. seq.), the Housing and Urban-Rural Recovery Act of 1983 (P.L. 98-181), the Housing and Community Development Technical
Amendments of 1984 (P.L. 98-479); and by the Housing and Community Development Act of 1987 (42 U.S.C. 3543). The information is being collected by HUD
to determine an applicant's eligibility, the recommended unit size, and the amount the tenant(s) must pay toward rent and utilities. HUD uses this information to
assist in managing certain HUD properties, to protect the Government's financial interest, and to verify the accuracy of the information furnished. HUD, lhe owner
or management agent (O/A), or the public housing agency (PHA) may conduct a computer match to verify the information you provide. This information may be
released lo appropriate Federal, State or local agencies, when relevant, and to civil, criminal or regulatory investigators and prosecutors. However, the information
will not be otheMise disclosed or released outside of HUD, except as permitted or required by law.
You must provide all of the information requested. Failure to provide anv information mav result in
onsent:
HUD, the O/A, and any PHA (or any employee of HUD, the O/A or the PHA) 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 the form HUD 9887 is restricted to the purposes cited on the form HUD 9887. Any person who knowingly or willfully
requests, obtains, or discloses any information under false pretenses concerning an applicant or tenant may be subject to a misdemeanor and fined not more
than $5,000.00.

Any applicant or tenant 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, the Owner or the PHA responsible for the unauthorized disclosure or improper use.

Original is retained on file at the project site ref. Handbooks 4350.3 Rev-1 , 4571.1 ,457112 & form HU D-9887 (0212007 )
4571.3 and HOPE ll Notice of Program Guidelines
 Applicant's/Tenant's Consent to the
U.S. Department of Housing
Release of lnformation
and Urban Development
Verification by Owners of lnformation
Office of Housing
Supplied by lndividuals Who Apply for Housing Assistance Federal Housing Commissioner

lnstructions to Ownens
Purpose of Requiring Consent to the Release of lnformation
1. Give the documents listed below to the applicants/tenants to sign. ln signing this consent form, you are authorizing the owner of the housing
Staple or clip them together in one package in the order listed. project to which you are applying for assistance to request information from
a. The HUD-9887/A Fact Sheet. i
third party about you. HUD requires the housing owner to verify all of the
b. Form HUD-9887. information you provide that affects your eligibility and level of benefits to
c. Form HUD-9887-A. ensure that you are eligible for assisted housing benefits and that these
d. Relevant verifications (HUD Handbook 4350.3 Rev. 1). benefits are set at the correct levels. Upon the requesl of the HUD office or
the PHA (as Contract Administrator), the housing Owner may provide HUD or
2. Verbally inform applicants and tenants that the PHA with the information you have submitted and the information the
a. They may take these forms home with them to read or to Owner received under this consent.
discuss with a third party of their choice and to return to sign
them on a date they have worked out with you, and
b. lfthey have a disability that prevents them from reading and/or Uses of lnformation to be Obtained
signing any consent, than you, the Owner, are required to The individual listed on the verification form may request and receive the
provide reasonable accommodations. information requested by the verification, subject to the limitations of this form.
HUD is required to protect the income verification it obtains in accordance with
3. Owners are required to give each household a copy ofthe the Privacy Act of 1974, S U.S.C. 552a. The Owner and the pHA are atso
HUD-9887/A Fact Sheet, form HUD-9887, and form HUD-9887-A required to protect the income information they obtain in accordance with any
after obtaining the required applicants/tenants signature(s). Also, applicable state privacy law. Should the Owner receive information from a
owners must give the applicants/tenants a copy of the signed third party that is inconsistent with the information you have provided, the
individual verification forms upon their request. Owner is required to notify you in writing identifying the information believed to
be incorrect. lf this should occur, you will have the opportunity to meet with the
lnstructions to Applicants and Tenants Owner to discuss any discrepancies.
This Form HUD-9887-A contains customer information and protections
concerning the HUD-required verifications that Owners must perform.

1. Read this material which explains: Who Must Sign the Consent Form
.HUD's requirements concerning the release of information, and Each member of your household who is at least 18 years of age, and each
Other customer protections. family head, spouse, or co-head, regardless of age must sign the relevant
2. Sign on the last page that: consent forms at the initial certification, at each recertification and at each
. you have read this form, or interim certification, if applicable. ln addition, when new adult members join
. the Owner or third party of your choice has explained it to you, the household and when members of the household become 1B years of age
and they must also sign the relevant consent forms.
. you consent to the release of information for the purposes and
uses described. Persons who apply for or receive assistance under the following
programs must sign the relevant consent forms:
Authority for Requiring Applicant's/Tenant's qonsent
to the Release of lnformation Rental Assistance Program (RAP)
Section 904 of the Stewart B. McKinney Homeless Assistance Amendments Rent Supplement
Act of 1988, as amended by section 903 of the Housing and Community Section 8 Housing Assistance Payments Programs (administered by
Development Act of 1992. This law is found at 42 U.S.C. 3344. the Office of Housing)
Section 202
ln part, this law requires you lo sign a consent form authorizing the Owner Section 202 and 811 PRAC
t0 request currenl or previous employers to verify salary and wage information Section 2021162 PAC
pertinent to your eligibility or level of benefits. Section 221(d)(3) Below Market lnterest Rate
ln addition, HUD regulations (24 CFR 5.659, Famity lnformation and Section 236
Verification) require as a condition of receiving housing assistance that you HOPE 2 Home Ownership of Multifamily Units
must sign a HuD-approved release and consent authorizing any depository or
private source of income to furnish such information that is necessary in
determining your eligibility or level of benefits. This includes information that
you have provided which will affect the amount of rent you pay. The
information includes income and assets, such as salary, welfare benefits and
interest earned on savings accounts. They also include certain adjustments
to your income, such as the allowances for dependents and for households
whose heads or spouses are elderly handicapped, or disabled; and
allowances for child care expenses, medical expenses, and handicap
assistance expenses.

Original is retained on file at the project site ref, Handbooks 4350.3 Rev-1 , 4571.1 ,457112 & 4571.3 form HUD-9887 - A (0212007 )
and HOPE ll Notice of Program Guidelines
 Failure to Sign the Consent Form
circumstances, the o/A may document the flre as to the reason
Failure to sign any required consent form may result for the deray
in the denial of and the specific plans to obtain the proper signature as soon
assislance or termination of assisted housing benefits. lf as possible.
an applicant is
denied assisrance for this reason, the o/A must foilow the notification
lndividual consents to the release of information expire .15 months after
procedures in Handbook 4350.3 Rev. 1. lf a lenant is denied they
assistance for are signed. The o/A may use these individuar consent forms during the 12i)
this reason, the O/A must follow the procedures set out in the lease.
days preceding the certification period, The O/A may also use these forms
during the certification period, but onry in cases where the o/A receives
Conditions information indicating that the information you have provided may be incorrect.
No action can be taken to terminate, deny, suspend, or reduce the assislance Other uses are prohibited.
your household receives based on information obtained about you under this
consent until the o/A has independenfly 1) verified the information you have
provided with respect to your erigibirity and rever of benefits and 2) with
The o/A may not make inquiries into information that is orderthan r2 months
respect to income (including both earned and unearned income), the O/A has unless he/she has received inconsistent information and has reason to believe
verified whether you actually have (or had) access to such income for your that the information that you have supplied is incorrect. lf this occurs. the o/A
own use, and verified the period or periods when, orwith respect to which you may obtain information within the last 5 years when you have received
actually received such income, wages or benefits. assistance.

I have read and understand this information on the purposes and uses of
information that is verified and consent to the release of lnformation for
A photocopy of the signed consent may be used to request the information
these purposes and uses.
authorized by your signature on the individual consent forms. This would
occur if the o/A does not have another individual verification consent with an
original signature and the O/A is required to send out another request for Name of Applicant or Tenant (Print)
verification (for example, the third party fails to respond). lf this happens, the
O/A may attach a photocopy of this consent to a photocopy of the individual
verification form that you sign. To avoid the use of photocopies, the O/A and
the individual may agree to sign more than one consent for each type of
verification that is needed. The O/A shall inform you, or a third party which I have read and understand the purpose of this consent and its uses and I
you designate, of the findings made on the basis of information verified under
understand that misuse of this consent can lead to personal penalties to
this consent and shall give you an opportunity to contest such findings in me.
accordance with Handbook 4380.3 Rev. 1.

The O/A must provide you with information obtained under this consent in Name of Project Owner or his/her representative
accordance with State privacy laws,
Property Manager
lf a member of the household who is required to sign the consent forms is
unable to sign the required forms on time, due to extenuating

Signature & Date

cc: Applicant/Tenant
Owner File

Penalties for Misusing this Consent:

HUD' the O/A' and any PHA (or any employee of HUD, the O/A, or the PHA) 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 the form HUD 9887-A is restricted to the purposes ciled on the form HUD 9887-A. Any person who knowingly and
willfully requests, obtains or discloses any information under false pretenses concerning an applicant or tenant may be subject to a misdemeanor and fined not
more than $5,000.00.

Any applicant or tenant 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, the O/A or the PHA responsible for the unauthorized disclosure or improper use.

Original is retained on file at the project site ref. Handbooks 4350.3 Rev-1 , 4571.1.457112 & 4571.3 form HUD-9887 - A (0212007)
and HOPE ll Notice of Program Guidelines
 VIOLENCE, DATING VIoLENCE Housing
U.S. Department of oMB Approvar No.2so2-0204
OR STALKING and Urban Development t:xp 6/30/20t7
Offlce of Housing

LEASE ADDENDUM
VIOLENCE AGAINST WOMEN AND JUSTICE DEPARTMENT REATITHORIZATION ACT oF 2OO5

TENANT LANDLORD UNIT NO. & ADDRESS

Fssrus GeRoeNs

This lease addendum adds the lbllowing paragraphs to the Lease between the above referenced
Tenant and Landlord.

Purpose of the Addendum

The lease for the above referenced unit is being amended to include the provisions of the
Violence Against Women and Justice Department ReauthorizationAct of 2005 (VAWA).

Conflicts with Other Provisions of the Lease

In case of any conflict between the provisions of this Addendum and other sections of the Lease.
the provisions of this Addendum shall prevail.

Term of the Lease Addendum

The effective date of this Lease Addendum is . This Lease Addendurn shall
continue to be in efTect until the Lease is terminated.

VAWA Protections

1 . The Landlord may not consider incidents of dornestic violence, dating violence or stalking as
serious or repeated violations of the lease or other "good cause" for termination of assistance
tenancy or occupancy rights of the victim of abuse.
2. The Landlord may not consider criminal activity directly relating to abuse, engaged in by a
member of a tenant's household or any guest or other person under the tenant's control, cause
for termination of assistance, tenancy. or occupancy rights if the tenant or an immediate
member of the tenant's family is the victim or threatened victim of that abuse.
3. The Landlord may request in writing that the victim. or a family member on the victim's
behalf, certify that the individual is a victim of abuse and that the Certification of Domestic
Violence, Dating Violence or Stalking, Form HUD-91066, or other documentation as noted
on the certification fbrm, be cornpleted and submitted within l4 business days, or an agreed
upon extension date, to receive protection under the VAWA. Failure to provide the
certification or other supporting documentation within the specified timefiame may result in
eviction.

Tenant Date

Landlord Date
Form HUD-91067
(e/2008)
 INSTRUCTIONS FOR COMPLETION OF DOCUMENT RECEIPT CERTIFICATION

We are required by the Department of Housing and Urban Development (HUD) to provide every
household with certain documents at application and every recertification. Please initial next to the
documents that you have received and siqn and date the bottom of the form.
INFORMATION REQUESTED

Certification: Mv initials certifv that I have received the followinq documents:

Residents Rights Brochure

-
HUD Fact Sheet Section 8 Properties, Section 2021811 (PRAC) Properties and/or
Section 236 Properties as applicable

"Applying for HUD Housing Assistance? Think About This... ls Fraud Worth lt?" Flier

EIV & You Brochure

HUD 9887/9887-4 Fact Sheet

Notice of Occupancy Rights Under the Violence Against Women Act (VAWA)

VAWA Certification Form - HUD 5382 Certification of Domestic Violence, Dating

Violence, Sexual Assault, or Stalking, and Alternate Documentation

Bed Bug Letter and Fact Sheet

Property Contact List

Nond iscrim ination Notice

Effective Communication Notice

Grievance Notice

At Application Only -- Owner's Notice No. 1 of Citizenship Requirements

At Application Only -- Tenant Selection Plan

Head of Household's Signature Date

Equal Housing Opportunity. The Landlord makes this housing available without regard to
race, color, religion, sex, National origin, familial status, disability (handicap), military status,
sexual orientation, gender identity or ancestry. The Landlord does not discriminate on the basis of
disability status in the admission or access to, or treatment or employment in, its federally assisted
programs and activities. The person named below has been designated to coordinate compliance
with the nondiscrimination requirements contained in the Department of Housing and Urban
Development's regulations implementing Section 504 (24 CFR, part 8 dated June 2, 1988) and is
the one who evaluates any reasonable accommodation or modification requests that have been
submitted. National Director of Training and Compliance, 26301 Curtiss Wright Parkway, Suite
300, Richmond Hts., OH 44143,216-472-1870 x 114 (TTY 7-1-1).
Rev.1l24l22 DOCUMENT RECEIPT CERTIFICATION