Appendix 6

Verification and Consent -- Guidance and Sample Formats

-   Appendix 6-A: Guidance for Development of Individual Consent Forms

-   Appendix 6-B: Verification of Disability -- Instructions to Owners
    and Sample Formats

-   Appendix 6-C: Guidance About Types of Information to Request When
    Verifying Eligibility and Income

APPENDIX 6: VERIFICATION AND CONSENT -- GUIDANCE AND\
SAMPLE FORMATS

This appendix contains three components.

**Appendix 6-A:** **Guidance for Development of Individual Consent
Forms** describes the required language that must be used when obtaining
an applicant/tenant's consent to seek third-party verification of
eligibility and income information, as well as a sample format.

**Appendix 6-B: Verification of Disability -- Instructions to Owners and
Sample Formats** provides additional instructions and sample formats for
verifying an applicant/tenant's disability status for eligibility, or
for receiving allowable income deductions based on disability.

**Appendix 6-C: Guidance About Types of Information to Request When
Verifying Eligibility and Income** presents guidance about the types of
information that are appropriate when an owner is seeking to verify an
applicant/tenant's eligibility or income information.

Page Left Intentionally Blank

Appendix 6-A: Guidance for Development of Individual Consent Forms

1\. [REQUIREMENTS FOR INDIVIDUAL CONSENT]{.underline}. See sample
consent below. Individual verification consent forms must contain the
following consumer protections:

a\. State in bold (or other emphasis) in a prominent place that the
applicant/tenant does not have to sign the consent if it is not clear
who will provide the information or who will receive the information.

> **NOTE:** This can be re-worded to suit the owner\'s individual style.
> This customer protection assures individuals that their consents will
> be used by authorized individuals only.
>
> **\"NOTE**: This information may have to be conveyed in languages
> other than English for LEP persons in accordance with HUD guidance.\"

b\. Include the following statement on the penalties for misusing the
consent:

\"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 \*\*408 (a) (6), (7) and (8).\*\*

c\. Request only that information necessary to determine the person\'s
eligibility or level of assistance.

+-----------------------------------------------------------------------+
| EXAMPLE -- Information That Is [Not]{.underline} Necessary to         |
| Determine\                                                            |
| Eligibility or Level of Assistance                                    |
|                                                                       |
| In a verification for termination of employment, it would not be      |
| appropriate to ask "would you rehire this person?" But, it would be   |
| appropriate to ask "do you anticipate rehiring this person and, if    |
| yes, when?"                                                           |
|                                                                       |
| In a medical verification, it would not be appropriate to ask the     |
| purpose of an office visit or to ask for a diagnosis.                 |
+-----------------------------------------------------------------------+

> **NOTE**: Concerning verifications of disability (handicap),
> **Appendix 6-B** provides a specific explanation to the
> applicant/tenant on the limitations on any verification of disability
> (handicap).

d\. Include the following certification statement to be signed by the
applicant/tenant:

> \"I hereby authorize the release of the requested information.
> Information 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 old, which would
> be authorized by me on a separate consent attached to a copy of this
> consent.\"

e\. Provide a space for the title, agency/organization, and signature of
the third party who is supplying the information. This information will
be provided by the third party. For example:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

NAME AND TITLE OF PERSON AGENCY/ORGANIZATION

SUPPLYING THE INFORMATION (PRINT)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

SIGNATURE DATE

2\. [SAMPLE VERIFICATION CONSENT FORMAT]{.underline}

The format on the next page shows a sample of how consent for
verification may be requested.

SAMPLE VERIFICATION CONSENT

DATE:

TO: (Name and address of third party FROM: (Name of individual

who is being requested to verify requesting the information,\
this information) title, name of housing project,\
address)

[RETURN THIS VERIFICATION TO THE PERSON LISTED ABOVE]{.underline} (or
other instruction to the third party to ensure that the verification is
returned to the right person. This is important because owners have a
responsibility to treat this information confidentially.)

SUBJECT: Verification of Information Supplied by an Applicant for
Housing Assistance

NAME

ADDRESS

This person has applied for housing assistance under a program of the
U.S. Department of Housing and Urban Development (HUD). HUD requires the
housing owner to verify all information that is used in determining this
person\'s eligibility or level of benefits.

We ask your cooperation in providing the following information and
returning it to the person listed at the top of the page. Your prompt
return of this information will help to ensure timely processing of the
application for assistance. Enclosed is a self-addressed, stamped
envelope for this purpose. The applicant/tenant has consented to this
release of information as shown below.

========================================================================

[INFORMATION BEING REQUESTED]{.underline}

(Owners: Fill in here the information requested. Consult **Appendix
[6]{.mark}-C** of this handbook for examples of relevant information
that owners may request from third parties in verifying several types of
income and information and household characteristics. This list of
information is not meant to be all-inclusive. Owners may add other
information as long as any additional information is relevant to
determining the individual's eligibility for assistance or level of
benefits. This instruction does not have to appear on an individual
consent.)

Name and Title of Person Firm/Organization\
Supplying the Information

Signature Date

========================================================================

========================================================================

RELEASE: I hereby authorize the release of the requested information.
Information 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 old, which would
be authorized by me on a separate consent attached to a copy of this
consent.

Signature Date

**Note to Applicant/Tenant:** You do not have to sign this form if
either the requesting organization or the organization supplying the
information is left blank.

========================================================================

PENALTIES FOR MISUSING THIS CONSENT:

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).\*\*

![](media/image1.png){width="3.4458333333333333in"
height="1.5208333333333333in"}

Appendix 6-B: Verification of Disability -- Instructions to Owners and
Sample Formats

**NOTE:** These verification instructions and sample formats are not to
be used when assigning accessible units.

1\. [EXPLANATION TO THE APPLICANT]{.underline}

(**Instruction to Owners:** This explanation is required. It may be in
the form of a cover letter or may appear directly on the verification
consent. Owners may edit the following explanation as long as the same
message is conveyed. This instruction does not have to appear on the
verification consent.)

HUD permits owners to verify that you have a disability only if:

1\) Your eligibility for admission is dependent on your being a person
with a disability; or

2\) You claim eligibility for deductions that are given to a person with
a disability.

The definitions of disability vary depending on the project you are
applying for or living in. The owner determines the definition(s) to use
by consulting with HUD Handbook 4350.3 REV-1. The third party from whom
this verification is being requested has knowledge of whether your
disability meets the applicable definition(s) of disability (or person
with a disability). An owner may request from a third party only the
minimum information necessary to determine whether you meet the
applicable definition of disability (or person with a disability). Any
other request for information about you is not relevant and may not be
asked (e.g., diagnosis, treatment plan).

\"NOTE: This information may have to be conveyed in languages other than
English for LEP persons in accordance with HUD guidance.\"

2\. [SAMPLE FORMATS]{.underline}

The two sample formats on the next page can be used to verify an
applicant/tenant's disability status for purposes of eligibility for
occupancy in properties/units where occupancy is restricted to disabled
families or persons with disabilities, or for income deductions based on
disability when determining an applicant/tenant's adjusted income.

Please note that if Item 4, on either sample format, is checked "YES",
the applicant/tenant does not meet HUD's definition of disability.

Page Left Intentionally Blank

SAMPLE VERIFICATION OF DISABILITY WHEN ELIGIBILITY FOR ADMISSION OR
QUALIFICATION FOR CERTAIN INCOME DEDUCTIONS IS BASED ON DISABILITY

FOR USE WITH **SECTION 202/8**, **SECTION 202 PAC**, **Section 202
PRAC,**\
AND **SECTION 811 PRAC**

DATE:

TO: (Name and address of third party FROM: (Name of individual

who is being requested to verify requesting the information,

this information) title, name of the housing project,

address)

[RETURN THIS VERIFICATION TO THE PERSON LISTED ABOVE]{.underline} (or
other instructions to the third party to ensure that the verification is
returned to the right person. This is important because owners have a
responsibility to treat this information confidentially.)

SUBJECT: Verification of Disability

NAME\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

ADDRESS\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

This person has applied for housing assistance under a program of the
U.S. Department of Housing and Urban Development (HUD). HUD requires the
housing owner to verify all information that is used in determining this
person's eligibility or level of benefits.

We ask your cooperation in providing the following information and
returning it to the person listed at the top of the page. Your prompt
return of this information will help to ensure timely processing of the
application for assistance. Enclosed is a self-addressed, stamped
envelope for this purpose. The applicant/tenant has consented to this
release of information as shown above.

===================================================================

INFORMATION BEING REQUESTED

For each numbered item below, mark an "X" in the applicable box that
accurately describes the person listed above.

> 1\. \_\_\_YES \_\_\_NO Has a physical, mental, or emotional impairment
> that is expected to be of long-continued and indefinite duration,
> substantially impedes his or her ability to live independently, and is
> of a nature that such ability could be improved by more suitable
> housing conditions.
>
> 2\. \_\_\_YES \_\_\_NO Is a person with a developmental disability, as
> defined in Section 102(7) of the Developmental Disabilities Assistance
> and Bill of Rights Act (42 U.S.C. 6001(8)), i.e., a person with a
> severe chronic disability that:

a\. Is attributable to a mental or physical impairment or combination of
mental and physical impairments;

> b\. Is manifested before the person attains age 22;
>
> c\. Is likely to continue indefinitely;
>
> d\. Results in substantial functional limitation in three or more of
> the following areas of major life activity;

(1) Self-care,

(2) Receptive and expressive language,

(3) Learning,

(4) Mobility,

(5) Self-direction,

(6) Capacity for independent living, and

(7) Economic self-sufficiency; and

> e\. Reflects the person\'s need for a combination and sequence of
> special, interdisciplinary, or generic care, treatment, or other
> services that are of lifelong or extended duration and are
> individually planned and coordinated.
>
> 3\. \_\_\_YES \_\_\_NO Is a person with a chronic mental illness,
> i.e., he or she has a severe and persistent mental or emotional
> impairment that seriously limits his or her ability to live
> independently, and whose impairment could be improved by more suitable
> housing conditions.
>
> 4\. \_\_\_YES \_\_\_NO Is a person whose sole impairment is alcoholism
> or drug addiction.
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> NAME AND TITLE OF PERSON FIRM/ORGANIZATION
>
> SUPPLYING THE INFORMATION
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> SIGNATURE DATE

===================================================================

========================================================================

RELEASE: I hereby authorize the release of the requested information.
Information 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 old, which would
be authorized by me on a separate consent attached to a copy of this
consent.

Signature Date

**Note to Applicant/Tenant:** You do not have to sign this form if
either the requesting organization or the organization supplying the
information is left blank.

========================================================================

PENALTIES FOR MISUSING THIS CONSENT:

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).\*\*

![](media/image1.png){width="3.4458333333333333in" height="0.90625in"}

Page Left Intentionally Blank

SAMPLE VERIFICATION OF DISABILITY WHEN ELIGIBILITY FOR ADMISSION OR
QUALIFICATION FOR CERTAIN INCOME DEDUCTIONS IS BASED ON DISABILITY

FOR USE WITH ALL PROGRAMS **EXCEPT** SECTION 202/8, SECTION 202 PAC,\
SECTION 202 PRAC, AND SECTION 811 PRAC

DATE:

TO: (Name and address of third party FROM: (Name of individual

who is being requested to verify requesting the information,

this information) title, name of the housing project,

address)

[RETURN THIS VERIFICATION TO THE PERSON LISTED ABOVE]{.underline} (or
other instructions to the third party to ensure that the verification is
returned to the right person. This is important because owners have a
responsibility to treat this information confidentially.)

SUBJECT: Verification of Disability

NAME\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

ADDRESS\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

This person has applied for housing assistance under a program of the
U.S. Department of Housing and Urban Development (HUD). HUD requires the
housing owner to verify all information that is used in determining this
person's eligibility or level of benefits.

We ask your cooperation in providing the following information and
returning it to the person listed at the top of the page. Your prompt
return of this information will help to ensure timely processing of the
application for assistance. Enclosed is a self-addressed, stamped
envelope for this purpose. The applicant/tenant has consented to this
release of information as shown above.

===================================================================

INFORMATION BEING REQUESTED

For each numbered item below, mark an "X" in the applicable box that
accurately describes the person listed above.

> 1\. \_\_\_YES \_\_\_NO Has a disability, as defined in 42 U.S.C. 423,
> which means;

a.  Inability to engage in any substantial gainful activity by reason of
    any medically determinable physical or mental impairment that can be
    expected to result in death or that has lasted or can be expected to
    last for a continuous period of not less than 12 months; or

b.  In the case of an individual who has attained the age of 55 and is
    blind, inability by reason of such blindness to engage in
    substantial gainful activity requiring skills or abilities
    comparable to those of any gainful activity in which he/she has
    previously engaged with some regularity and over a substantial
    period of time.\
    \
    For the purposes of this definition, the term blindness, as defined
    in section 416(i)(1) of this title, means central vision acuity of
    20/200 or less in the better eye with use of a correcting lens. An
    eye which is accompanied by a limitation in the fields of vision
    such that the widest diameter of the visual field subtends an angle
    no greater than 20 degrees shall be considered for the purposes of
    this paragraph as having a central visual acuity of 20/200 or less.

2\. \_\_\_YES \_\_\_NO Has a physical, mental, or emotional impairment
that:

> a\. Is expected to be of long-continued and indefinite duration;
>
> b\. Substantially impedes his or her ability to live independently;
> and

c\. Is of such a nature that the ability to live independently could be
improved by more suitable housing conditions.

3\. \_\_\_YES \_\_\_NO Has a developmental disability as defined in
Section 102(7) of the Developmental Disabilities Assistance and Bill of
Rights Act 42 U.S.C. 6001(8)), i.e., a person with a severe chronic
disability that:

> a\. Is attributable to a mental or physical impairment or combination
> of mental and physical impairments;

b\. Is manifested before the person attains age 22;

> c\. Is likely to continue indefinitely;
>
> d\. Results in substantial functional limitation in three or more of
> the following areas of major life activity:

(1) Self-care,

(2) Receptive and expressive language,

(3) Learning,

(4) Mobility,

(5) Self-direction,

(6) Capacity for independent living, and

(7) Economic self-sufficiency; and

> e\. Reflects the person\'s need for a combination and sequence of
> special, interdisciplinary, or generic care, treatment, or other
> services that are of lifelong or extended duration and are
> individually planned and coordinated.

4\. \_\_\_YES \_\_\_NO Is the above a person \*\*whose\*\* disability is
based **solely** on any drug or alcohol dependence \*\*(the person has
no other disability which meets the above definition)\*\*.

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> NAME AND TITLE OF PERSON FIRM/ORGANIZATION
>
> SUPPLYING THE INFORMATION
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> SIGNATURE DATE

========================================================================

RELEASE: I hereby authorize the release of the requested information.
Information 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 old, which would
be authorized by me on a separate consent attached to a copy of this
consent.

Signature Date

**Note to Applicant/Tenant:** You do not have to sign this form if
either the requesting organization or the organization supplying the
information is left blank.

========================================================================

PENALTIES FOR MISUSING THIS CONSENT:

![](media/image1.png){width="3.4458333333333333in"
height="0.8666666666666667in"}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).\*\*

Page Left Intentionally Blank

Appendix 6-C: Guidance About Types of Information to Request\
When Verifying Eligibility and Income

Paragraph 1.c of **Appendix 6-A** states that owners may request only
that information necessary to determine the person\'s eligibility or
level of assistance. The first paragraph under most of the types of
income listed below provides information that would meet this
requirement. For some types of income listed below, appropriate requests
for information are combined with the types of verification that are
permitted. In deciding whether to add information to a particular
verification request that is not listed below, the owner must ask: Is
this information necessary to determine the individual\'s eligibility
for assistance or level of assistance? If the answer is \"yes\", then
the owner may verify that information. If the answer is \"no\", then the
owner may not verify that information

\"NOTE: This information may have to be conveyed in languages other than
English for LEP persons in accordance with HUD guidance.\"

A. **Employment Income**

1\. [Relevant information to verify with third party]{.underline}:

a\. Nonmilitary employment

> \(1\) Date first employed,
>
> \(2\) Base pay rate (Gross) (check one)
>
> Per hour \$\_\_\_\_\_\_ or per week \$\_\_\_\_\_\_
>
> OR per month \$\_\_\_\_\_

Date present rate became effective \_\_\_\_\_\_\_\_\_\_\_\_

> Expected average hours to be worked during next 12 calendar months at
> base pay rate \_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Per week \_\_\_\_\_\_\_\_\_\_ or per month\_\_\_\_\_\_\_\_,

\(3\) Overtime pay rate

Per hour \$\_\_\_\_\_\_\_\_\_\_\_\_

> Expected average number of hours to be worked per week during next 12
> calendar months \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,
>
> \(4\) Other compensation not included above (specify for commissions,
> bonuses, tips, etc.)

For \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \$\_\_\_\_\_\_\_\_\_\_ per
\_\_\_\_\_\_\_\_\_,

> \(5\) Total anticipated base pay earnings for the next 12 calendar
> months \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,
>
> Total anticipated overtime earnings for the next 12 calendar months
> \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,

(6) Medical insurance premium deducted (if any). (This would be relevant
    only for families eligible for the medical deduction.),\
    \
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(7) Has employment been terminated?
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> If yes, is individual eligible for unemployment benefits?
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> b\. Military employment
>
> \(1\) Years \_\_\_\_ and months \_\_\_\_\_ of services for pay
> purposes.
>
> Number of dependents claimed\_\_\_\_\_\_\_\_\_\_\_\_,
>
> \(2\) Monthly income from the following sources:
>
> Base pay and longevity pay \$\_\_\_\_\_\_\_\_\_\_\_
>
> Proficiency pay \$\_\_\_\_\_\_\_\_\_\_\_
>
> Sea and foreign duty pay \$\_\_\_\_\_\_\_\_\_\_\_
>
> Hazardous duty pay \$\_\_\_\_\_\_\_\_\_\_\_
>
> Imminent danger pay \$\_\_\_\_\_\_\_\_\_\_\_
>
> Subsistence allowance \$\_\_\_\_\_\_\_\_\_\_\_
>
> Quarters allowance\
> (Include only amount contributed by government)
> \$\_\_\_\_\_\_\_\_\_\_\_
>
> Other (explain) \$\_\_\_\_\_\_\_\_\_\_\_
>
> TOTAL AMOUNT RECEIVED MONTHLY \$\_\_\_\_\_\_\_\_\_\_\_.

2\. [Acceptable forms of verification]{.underline}:

> a\. Employment verification form completed by the employer verifying
> frequency of pay, effective date of the last pay increase, and
> probability and effective date of any increase during the next 12
> months;
>
> b\. Check stubs or earning statements showing employee\'s gross pay
> per pay period and frequency of pay;
>
> c\. W-2 forms if applicant has had the same job for at least two years
> and pay increases can be accurately projected; and
>
> d\. Notarized statements, affidavits or income tax returns signed by
> the applicant describing self-employment and amount of income or
> income from tips and other gratuities.

B. **Date Employment Terminated**

1\) [Relevant information to verify with third party]{.underline}:

> a\. Date of hire;
>
> b\. Date of termination;
>
> c\. Last day actually worked;
>
> d\. Do you anticipate rehiring this employee? If yes, when?
>
> e\. Will the employee receive additional paychecks for worker's
> compensation?
>
> If yes, provide the name and address of the company through which this
> can be verified.
>
> f\. Is employee eligible for unemployment benefits?
>
> g\. Total severance pay anticipated for the next 12 months.

2\. [Acceptable forms of verification:]{.underline}

> a\. Termination of employment verification;
>
> b\. Letter from employer stating date of termination; and
>
> c\. Letter from an agency providing unemployment compensation stating
> that the individual\'s employment terminated and that unemployment
> benefits will begin.
>
> C. **Social Security and Supplementary Security Income (SSI)**
>
> 1\. [Relevant information to verify with third party]{.underline}. The
> following information is generally available from an award or benefit
> letter.
>
> a\. Name of original annuitant;
>
> b\. Pension claim number or social security number of person receiving
> the pension claim;
>
> c\. Current monthly gross amount of pension or annuity;
>
> d\. Deductions from gross amount for medical insurance premiums;
>
> e\. Date benefits began;
>
> f\. Effective date of current amount;
>
> g\. For social security, ask: Has the monthly payment been reduced for
> overpayment of previous benefits? If so, by how much?

2\) [Acceptable forms of verification]{.underline}:

> a\. [Initial occupancy]{.underline}. At initial occupancy, acceptable
> forms of verification are:

-   Benefit verification form completed by agency providing the
    benefits;

-   Award or benefit notification letters prepared and signed by the
    authorizing agency. (Since checks or bank deposit slips show only
    net amounts remaining after deducting supplemental security income
    or Medicare, they may be used only when award letters can\'t be
    obtained.) If the applicant does not have his or her award letter,
    the applicant may obtain it by calling 800-772-1213.

b.  [Annual recertification]{.underline}. At annual recertification, the
    owner can verify benefit information by obtaining a Benefit History
    Report from TASS. These Benefit History Reports are generated three
    to four months before annual recertification dates and are available
    on the TASS website. TASS is provided a monthly TRACS file for
    households whose annual recertification date is four months hence.
    TASS processes that data through the Social Security Administration
    databases and places the Benefit History Reports on their website
    for sites to download. If the owner cannot obtain this report from
    TASS, the owner uses the verification methods for initial occupancy.

    **NOTE**: Failure to obtain a Benefit History Report from TASS is
    not an indication that the tenant does not receive benefits. Due to
    data sharing limitations between existing data systems, it is
    possible for a tenant to receive benefits on which the owner cannot
    obtain a Benefit History Report.

> D. **Pensions and Disability Income Other Than from the Social
> Security Administration**
>
> This paragraph is not suggesting that owners group verifications of
> these different sources of income into one verification. Owners may
> have to adapt the questions, depending on the source of income being
> verified. This paragraph provides suggestions on the types of
> questions that are appropriate to ask a third party.

1\. [Relevant information to verify with third party:]{.underline}

> a\. Name of original annuitant;
>
> b\. Pension claim number or social security number of person receiving
> the pension claim;
>
> c\. Current monthly gross amount of pension or annuity;
>
> d\. Deductions from gross amount for medical insurance premiums;
>
> e\. Date benefits began;
>
> f\. Effective date of current amount;
>
> g\. For annuities, ask: Did the individual invest in an annuity? If
> yes, what is the amount invested? What is the amount received to date
> from the annuity? Does the individual receive regular payments? When
> are they received (monthly, annually)?
>
> h\. For pensions and annuities, ask: Is the individual reimbursed for
> medical costs?

2\) [Acceptable forms of verification]{.underline}:

> a\. Benefit verification form completed by the company/agency
> providing the benefits;
>
> b\. Award or benefit notification letters prepared and signed by the
> authorizing company/agency. (Checks or bank deposit slips show only
> net amounts remaining after deductions.)

E. **Unemployment Compensation**

1\. [Relevant information to verify with third party]{.underline}:

> a\. Gross weekly payment;
>
> b\. Date of initial payment;
>
> c\. Duration of benefits: \_\_\_\_\_\_ weeks;
>
> d\. Is the claimant eligible for further benefits?
>
> e\. If yes, how many weeks?
>
> f\. If no, what is the date the benefits are terminated?

2\. [Acceptable forms of verification:]{.underline}

> a\. Verification form completed by the unemployment compensation
> agency; and
>
> b\. Records from unemployment office stating payment dates and
> amounts.

F. **Public Benefits**

1\. [Relevant information to verify with third party]{.underline}:

> a\. Number of members in the family;
>
> b\. Names of the children for whom benefits are received and their
> social security numbers;
>
> c\. Date of initial assistance;
>
> d\. Is recipient covered by Medicaid? If yes, what is the Medicare
> spend down amount?
>
> e\. Does the recipient meet his/her spend down amount each period?
>
> f\. What is the rate per month under the following grant:

(1) Temporary Assistance to Needy Families (TANF),

(2) Supplemental Social Security,

(3) Other assistance: Type \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, and

> g\. The following question applies only to \"as-paid\" States only:
> Amount specifically designated for shelter and utilities (This is the
> maximum allowance for rent and utilities);
>
> h\. The grant is increased by the following amounts (Specify purpose):

(1) Employment income \$ \_\_\_\_\_\_\_\_\_\_\_\_\_\_

(2) Child care allowance \$ \_\_\_\_\_\_\_\_\_\_\_\_\_\_

(3) Transportation \$ \_\_\_\_\_\_\_\_\_\_\_\_\_\_

(4) Other \_\_\_\_\_\_\_\_\_\_\_\_\_ \$ \_\_\_\_\_\_\_\_\_\_\_\_\_\_;

> i\. The grant is reduced by the following amounts:

(1) Alimony \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(2) Child support \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(3) Other (specify)
    \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_;

> j\. Is there anything else that will influence the amount of the
> grant? If yes, specify purpose and amount.
> \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> k\. Has the monthly payment been reduced for overpayment of previous
> benefits? If so, by how much? \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> l\. TOTAL MONTHLY GRANT \$ \_\_\_\_\_\_\_\_\_\_\_\_\_.

2\. [Acceptable forms of verification:]{.underline}

> a\. [All welfare programs]{.underline}. Welfare agency\'s written
> statements as to type and amount of assistance family is now receiving
> and any changes in assistance expected during the next 12 months;
>
> b\. [Additional information for \"as-paid\" programs]{.underline}.
> Welfare agency\'s written schedule or statement that describes how the
> \"as-paid\" system works, the maximum amount a family may receive for
> shelter and utilities and, if applicable, any factors used to ratably
> reduce the client\'s grant.

G. **Alimony or Child Support Payments**

1\. [Relevant information to verify with third party:]{.underline}

a\. Amount of alimony or child support being provided to the family;

> b\. Will such amounts be terminated within the next 12 months. If so,
> when?

2\. [Acceptable forms of verification]{.underline}:

> a\. Copy of a separation or settlement agreement or divorce decree
> stating amount and type of support and payment schedules;
>
> b\. A letter from the person paying the support;
>
> c\. Copy of latest check. Owner must record the date, amount, and
> number of check; and
>
> d\. Applicant\'s notarized statement or affidavit of amount received
> or that support payments are not being received and the likelihood of
> support payments being received in the future.
>
> H. **Net Income from a Business**\
> \
> The following documents show income for the prior years. Owners must
> consult with tenants and use this data to estimate income for the next
> 12 months.
>
> 1\. IRS Tax Return, Form 1040, including any:
>
> a\. Schedule C (Small Business);
>
> b\. Schedule E (Rental Property Income); and
>
> c\. Schedule F (Farm Income).
>
> 2\. An accountant\'s calculation of depreciation expense, computed
> using straight-line depreciation rules. (Required when accelerated
> depreciation was used on the tax return or financial statement.)
>
> 3\. Audited or unaudited financial statement(s) of the business.
>
> 4\. Loan Application listing income derived from the business during
> the previous 12 months.
>
> 5\. Applicant\'s notarized statement or affidavit as to net income
> realized from the business during the previous years.

I. **Recurring Gifts**

[Acceptable forms of verification]{.underline}:

> 1\. Notarized statement or affidavit signed by the person providing
> the assistance. It must give the purpose, dates and value of gifts.
>
> 2\. Applicant\'s notarized statement or affidavit that provides the
> purpose, dates and value of gifts.

J. **Family Assets Now Held**

> 1\) [Relevant information to verify with third party:]{.underline}
>
> For non-liquid assets, collect enough information to determine the
> current cash value---the net amount the family would receive if the
> asset were converted to cash. (See paragraph 5.7.)
>
> a\. Type of account;
>
> b\. Current balance or, for checking accounts, the average balance for
> the last six months;
>
> c\. Date account opened;
>
> d\. Date account closed;
>
> e\. Is this an interest bearing account? If so, what is the interest
> rate?
>
> f\. For trusts:
>
> \(1\) What is the value of the trust fund?
>
> \(2\) What is the anticipated amount of income to be earned by the
> trust over the next 12 months?
>
> \(3\) What is the amount anticipated to be distributed over the next
> 12 months?
>
> g, For property, what is the equity value?
>
> 2\) [Acceptable forms of verification:]{.underline}
>
> a\. Verification forms, letters, or documents from a financial
> institution, broker, etc.;
>
> **NOTE:** When financial institutions charge a fee to the applicant or
> tenant for providing verifications, the forms of verification in
> paragraph b) below would be the preferred method.
>
> b\. Account statements, passbooks, broker\'s quarterly statements
> showing value of stocks or bonds, etc., and the earnings credited to
> the applicant's account statements, or financial statements completed
> by a financial institution or broker;
>
> **NOTE:** The owner must adjust the information provided by the
> financial institution to project earnings expected for the next 12
> months.
>
> c\. Quotes from a stockbroker or realty agent as to net amount family
> would receive if they liquidated securities or real estate;
>
> d\. Copy of IRS Form 1099 prepared by the financial institution
> showing the amount of income provided by the asset;
>
> e\. Real estate tax statements if tax authority uses approximately
> market value;
>
> f\. Copies of closing documents showing the selling price, the
> distribution of the sales proceeds and the net amount to the
> individual;
>
> g\. Appraisals of personal property held as an investment; and
>
> h\. Applicant\'s notarized statements or signed affidavits describing
> assets or verifying cash held at the applicant\'s home or in safe
> deposit boxes.
>
> K. **Assets Disposed of for Less than Fair Market Value During Two
> Years Preceding Effective Date of Certification or Recertification**\
> \
> (See paragraph 5.7 G.6.) Suggested information to obtain and
> acceptable forms of verification are included below.
>
> 1\. For all certifications and recertifications except those prepared
> for BMIR tenants, family\'s certification as to whether any member has
> disposed of assets for less than fair market value during the two
> years preceding effective date of the certification or
> recertification.
>
> 2\. If the family certifies that they did dispose of assets for less
> than fair market value a certification that shows:
>
> a\. All assets disposed of for less than fair market value;
>
> b\. The date they disposed of the assets;
>
> c\. The amount the family received; and
>
> d\. The assets\' market value at the time of disposition.
>
> L. **Income from Sale of Real Property Pursuant to a Purchase Money
> Mortgage, Installment Sales Contract, or Similar Arrangement**\
> \
> The following provide suggested information to verify with a third
> party and acceptable forms of verification:
>
> 1\. A letter from an accountant, attorney, real estate broker, the
> buyer, or a financial institution stating interest due for next 12
> months. (A copy of the check paid by the buyer to the applicant is not
> sufficient since appropriate breakdowns of interest and principal are
> not included.)
>
> 2\. Amortization schedule showing interest for the 12 months following
> the effective date of the certification or recertification.
>
> M. **Rental Income from Property Owned by Applicant/Tenant\
> \
> **The following provide suggested information to verify with a third
> party and acceptable forms of verification:
>
> 1\. IRS Form 1040 with Schedule E (Rental Income).

2\. Copies of latest rent checks, leases, or utility bills.

> 3\. Documentation of applicant\'s/tenant\'s income and expenses in
> renting the property (tax statements, insurance premiums, receipts for
> reasonable maintenance and utilities, bank statements or amortization
> schedules showing monthly interest expense).
>
> 4\. Lessee\'s written statement identifying monthly payments due the
> applicant and applicant\'s affidavit as to net income realized.
>
> N. **Full-Time Student Status**\
> \
> The following provide suggested information to verify with a third
> party and acceptable forms of verification:

1\. Written verification from the registrar\'s office or appropriate
school official.

> 2\. School records indicating enrollment for sufficient number of
> credits to be considered a full-time student by the school.

O. **Child Care Expenses**\
\
The following provide suggested information to verify with a third party
and acceptable forms of verification:

1\. Written verification from the person who receives the payments.

> 2\. Verifications must specify the hours and days during which the
> care is provided, the names and ages of the children cared for, and
> the frequency and amount of compensation received. (Owners should
> recognize that child care costs may be higher during summer and
> holiday recesses.)
>
> **NOTE:** Owners may want to ask the verifying party to indicate
> children age 12 or younger.
>
> 3\. Applicant\'s certification as to whether any of those payments
> have been or will be reimbursed by outside sources.
>
> **NOTE:** Owners may wish to use separate verification consents for
> child care and disability (handicap) care.
>
> P. **Medical Expenses**\
> \
> The following provide suggested information to verify with a third
> party and acceptable forms of verification:
>
> 1\. Written verification by a doctor, hospital or clinic personnel,
> dentist, pharmacist, etc., of:
>
> a\. The estimated medical costs to be incurred by the applicant and of
> regular payments due on medical bills;
>
> b\. The extent to which those expenses will be reimbursed by insurance
> or a government agency; and
>
> c\. Whether the provider accepts Medicare assignment.
>
> 2\. The insurance company\'s or employer\'s written confirmation of
> health insurance premiums to be paid by the applicant.
>
> 3\. Social Security Administration\'s written confirmation of Medicare
> premiums to be paid by the applicant over the next 12 months.
>
> 4\. For attendant care:
>
> a\. Doctor\'s certification that the assistance of an attendant is
> medically necessary;
>
> b\. Attendant\'s written confirmation of hours of care provided and
> amount and frequency of payments received from the family (or copies
> of cancelled checks the family used to make those payments); and
>
> c\. Applicant\'s certification as to whether any of those payments
> have been or will be reimbursed by outside sources.
>
> 5\. Receipts, cancelled checks, or pay stubs that indicate health
> insurance premium costs, etc., that verify medical and insurance
> expenses likely to be incurred in the next 12 months.
>
> 6\. Copies of payment agreements with medical facilities or cancelled
> checks that verify payments made on outstanding medical bills that
> will continue over all or part of the next 12 months.
>
> 7\. Receipts or other record of medical expenses incurred during the
> past 12 months that can be used to anticipate future medical expenses.
> Owners may use this approach for \"general medical expenses\" such as
> non-prescription drugs and regular visits to doctors or dentists, but
> not for one-time, nonrecurring expenses from the previous year.

Q. **Need for Larger Unit Because of Physical or Mental Disability
(Handicap)**\
\
A health care provider (that is deemed a reliable source) must certify
that such a unit is necessary because of a disability (handicap). As a
routine practice, owners should accept the recommendation of the
individual as to which health care provider can provide this
information.

R. **Disabled (Handicap) Assistance Expense**

> 1\. Attendant care:
>
> a\. Attendant\'s written certification as to amount received from the
> applicant/tenant, frequency of receipt, hours of care provided, and/or
> copies of cancelled checks applicant/tenant used to make those
> payments; and
>
> b\. Family\'s written certification as to whether they receive
> reimbursement for any of the attendant care expenses and the amount of
> any reimbursement received.
>
> 2\) Auxiliary apparatus: Receipts for purchases of, or evidence of
> monthly payments for auxiliary apparatus.
>
> 3\) In all cases:
>
> a\. As routine practice, owners should accept the individual\'s
> written statement that an auxiliary apparatus or attendant care is
> necessary for employment. If the owner determines that verification is
> necessary in a particular case, the owner should obtain written
> certification from a health care provider (that is deemed a reliable
> source) or a rehabilitation agency that the family member who is a
> person with a disability (handicap) requires the services of an
> attendant or the use of auxiliary apparatus to permit this family
> member to be employed or to enable another family member to be
> employed. This paragraph follows the practices used in Chapter 2
> regarding individuals\' requests for reasonable accommodations where
> the owner relies on the individual to determine what is needed.
>
> b\. Family\'s written certification as to whether they receive
> reimbursement for any of the auxiliary apparatus expenses and the
> amount of any reimbursement received.

S. **Family Type and Membership in Family**

> 1\. For elderly household where the head, co-head, or spouse is 62
> years of age or older verification of age may be provided by:
>
> a\. Copy of a birth certificate, baptismal certificate, census record,
> official record of birth or other authoritative document; or
>
> b\. Receipt of supplemental security income old age benefits or social
> security retirement benefits.
>
> 2\. For disability (because the individual\'s eligibility for
> admission is dependent on his/her being a person with a disability
> \[handicap\] or because the individual claims eligibility for income
> deductions that are given to persons with disabilities \[handicaps\])
> verification of disability (handicap) may be provided by:
>
> a\. Receipt of supplemental social security disability or social
> security disability benefits, which would provide verification that an
> individual met the definition of \"person with disabilities\" as shown
> in Definition E of Figure 3-6 in Chapter 3 of this handbook; or
>
> b\. Certification by a health care provider (that is deemed to be a
> reliable source) that the individual meets the relevant definition of
> a \"person with a disability (handicap)\" for the particular project.
>
> **IMPORTANT**: See **Appendix [6]{.mark}-B** for the limitations on
> information that may be verified. **Appendix [6]{.mark}-B** also
> requires the owner to provide an explanation to the applicant/tenant
> describing these limitations. In particular, the consent should
> request the third party to identify any of the relevant definitions
> that apply to the individual. Any other request for information about
> the individual is not relevant and may not be asked (e.g., diagnosis,
> treatment plan).
>
> 3\. For family members younger than age 18, verification of age may be
> provided by birth certificate, adoption papers, and/or custody
> agreements.

T. **Statutory and HUD Regulatory Preferences** **-- Displacement by
Government Action or Presidentially Declared Disaster**\
\
(Applicable only to 221(d)(3) BMIR and Section 236 units):

> 1\. [Relevant information to verify with third party:]{.underline}
>
> Date of displacement, or, if displacement has not yet occurred, the
> anticipated date of displacement; The applicant will be displaced if
> the applicant has vacated or will have to vacate his/her housing unit
> as a result of one or both of the following actions:
>
> a\. A presidentially declared disaster, such as a hurricane, flood or
> fire, that has made the unit uninhabitable; or
>
> b\. Code enforcement, public improvement, or development program
> activities by a U.S. agency or a State or local government body or
> agency.
>
> 2\) [Acceptable forms of verification]{.underline}:
>
> a\. [Displacement by disaster]{.underline}. Verification from a unit
> or agency of government that an applicant has been or will be
> displaced as a result of a presidentially declared disaster that
> results in the uninhabilitability of an applicant\'s unit.
>
> b\. [Displacement by government action]{.underline}. Verification from
> a unit or agency of government that an applicant has been or will be
> displaced by activity carried on by an agency of the United States or
> by an State or local government body or agency in connection with code
> enforcement or a public improvement or development program.