LIVE-IN ATTENDANT / AIDE CERTIFICATION
Property:Attendant or Aide Name: / Telephone:
Address:
Name of Agency or Physician Prescribing Service: / Telephone:
Address:
Name of Resident(s)/Applicant(s): / Apt #:
The person you are caring for has applied for admission to or is residing in our affordable housing property that is governed by the federal government. We are required to verify your live-in attendant/aide status prior to granting eligibility to the applicant/resident and your admission to the household. To be qualified as a live-in attendant, you must attest to all of the following statements:
l I am not responsible for the financial support of said person.
l Said person is not responsible for my financial support.
l I would not otherwise be living in the unit EXCEPT to provide the necessary support and care to allow said person to live independently.
l I understand that I have NO survivorship rights to this apartment and that if said person moves-out for any reason, I must vacate the apartment as well. I understand this apartment is governed by a federal government housing program and that the occupants of such an apartment unit must meet all eligibility requirements of the program. I understand that I have not been certified as such and that my only reason for living in the apartment is to provide supportive care to said person.
l I authorize Management to make any and all inquiries to verify this certification either directly or though information exchanged now or later with rental, criminal and credit screening services, and to contract previous and current housing providers or other sources for verification confirmation which may be released to appropriate Federal, State, or local agencies. I authorize Management to obtain one or more “consumer reports” as defined in the Fair Credit Reporting Act, 15 U.S.C. Section 1681a(d), seeking information on my character, general reputation, personal characteristics, criminal background, and/or mode of living.
Signature of Attendant/Aide: / Date:Signature of Applicant/Resident: / Date:
PLEASE READ THE STATEMENTS BELOW CAREFULLY BEFORE SIGNING THIS CERTIFICATION
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, Rural Housing Services (RHS) and any owner (or any employee of HUD, the RHS 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 willfully 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 or information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the RHS 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. 408 (a) (6), (7) and (8).**
Live-In Attend Affidavit (10/07) Page 1 of 1 TC-48