CHILD SUPPORT/NON-SUPPORT SELF-AFFIDAVIT
MANAGEMENT INSTRUCTIONS: This affidavit is needed at Application AND at each Annual Recertification. It is needed at interims and initials only if theses specific circumstances have changed. YOU are to interview the applicant/resident, Mark the box next to the number(s) which apply, and complete the requested information. Required copies MUST be obtained for the file to complete this affidavit.
1. I CERTIFY I AM RECEIVING CHILD SUPPORT AS STATED in my divorce decree, settlement agreement, paternity agreement, or other court order for the following child/children:
Name Age Name Age
Name Age Name Age
REQUIRED ATTACHMENT FOR #1: Copy of divorce decree, settlement agreement, paternity agreement, or other court order which specifies the current child support amount.
2. I CERTIFY I AM NOT RECEIVING CHILD SUPPORT AS STATED in my divorce decree, settlement agreement, paternity agreement, or other court order for the following child/children:
Name Age Name Age
Name Age Name Age
(CHECK ONE) AND
_____A. I HAVE MADE REASONABLE EFFORT TO COLLECT the amounts due WITHIN THE PAST 12 MONTHS, including filing with courts or agencies responsible for enforcing payments. I anticipate receiving support in the amount of $______during the NEXT 12 months.
REQUIRED ATTACHMENT FOR 2.A.: Copy of divorce decree, settlement agreement, paternity agreement, or other court order which specifies the current child support amount AND copy of proof of efforts to collect support.
OR
_____B. I AM NOT ACTIVELY PURSUING THE COLLECTION of the child support and understand that because of this, the FULL AMOUNT STATED in my divorce decree, settlement agreement, paternity agreement, or other court order MUST BE COUNTED AS INCOME to me.
REQUIRED ATTACHMENT FOR 2.B.: Copy of divorce decree, settlement agreement, paternity agreement, or other court order which specifies the current child support amount.
3. I RECEIVE SUPPORT for the following child/children, as stated below, but there was NO COURT ORDER OF ANY KIND establishing an amount of child support to be paid:
Name Age Amount $ Per (wk? mo?)
Name Age Amount $ Per (wk? mo?)
4. I RECEIVE NO SUPPORT for the following child/children AND there has NEVER BEEN A COURT ORDER establishing an amount of child support to be paid:
Name Age
Name Age
WARNING: My signature below certifies that my statements above are true and correct and have been completed to the best of my knowledge. Falsification is also grounds for application cancellation, termination of assistance, and/or eviction. I can lose the subsidy HUD pays and/or have my rent increased. I understand that any assistance paid in error must be returned to HUD.
______
Resident/Applicant Signature Date
______
Owner/Agent Witness Print Name Date
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, the PHA and any owner (or any employee of HUD, the PHA 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 of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the PHA 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)
10.25.1 Revision 1/1/2013 Effective 1/1/2013