AFFIDAVIT AND CLARIFICATION OF ASSETS LISTED JOINTLY
Date: / (Property Stamp)Phone: Fax:
Applicant/Resident:
Address:
Unit #:
Type of Asset(s):
Account Number(s):
Other Account Holder(s) Name(s)::
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).**
Dear Applicant/Resident: Please read below and check the box or boxes that apply to the circumstances regarding the joint asset account(s) listed above:
1. / I/We own the asset(s) listed above. Any income earned accrues to my/our benefit.I/We and the person(s) listed above share equal access to the account and any income
earned from the asset(s) listed above. We share equally or ______(enter percentage/portion).
The asset(s) listed above are not accessible to me. The asset(s) cannot be converted to cash income for my/our benefit. (For example: pending divorce, other domestic situation, irrevocable trust, etc.)
2. / The person(s) listed above is/are not a member of my/our household and,
The above listed person(s) is/are named as my/our Power of Attorney on the assets(s) listed above solely for emergency purposes. This person receives no income or benefits from this account.
Question 2 continued on next page.
AFFIDAVIT AND CLARIFICATION OF ASSETS LISTED JOINTLY
(Continued from page 1)______Apartments Applicant/Resident: ______Unit #:______
The above listed person(s) are listed on my/our account solely for emergency purposes to handle my/our affairs. The above person(s) will not receive any income earned on this account as part of his/her income; nor, will he/she be responsible for any related expenses.
3. / The person(s) listed above are not a member of my/our household and,
The asset(s) listed above and any income earned, accrue to the benefit of that/those person(s).
The person(s) listed above is/are responsible for all expenses incurred on income generated by the asset(s).
I/We am/are named on his/her/their asset(s) listed above solely for emergency purposes to handle his/her affairs. I/We will not receive any income earned nor will I/we be responsible for any related expenses for this account.
I/We am/are names as his/her Power of Attorney on the asset(s) listed above solely for emergency purposes. I/We receive no income or benefits from this account.
I/We certify that the above statements are true and accurate to the best of my/our knowledge. I/We have provided this affidavit to substantiate my/our claims.
Applicant/Resident Signature: / Date:Co-Head Applicant/Resident Signature: / Date:
Signature(s) must be notarized below:
Subscribed and sworn to before me this ______day of ______, ______
Signature of Notary Public:
My Commission Expires:
Clarification Assets Jointly (06/08)Page 1 of 2TC-15a