Sample Self Certification Household Assets & Income from Assets

HOH Name: UnitNo: ______

Streamlined Verification for Assets? / Yes No If Yes, Certification Contains Information for Year
1st year cert (Traditional Verification)
2 (Self Certification)
3 (Self Certification)

An asset, as defined by HUD, is cash or something that you own that can be converted to cash. Personal property, such as clothes, wedding rings, personal vehicles, etc. are not counted as assets.

I/we do not have any assets at thistime.(If this is the case, continue to page 2 and answer questions about disposed assets)

My/our assetsinclude:

(A)
Fair Market Value / (B)
Annual Interest % / Annual Incomeincluding dividends / Regular Periodic Payments (per month, quarter, year) / Cash Value
of Asset / Type of Asset
$ / $ / $ / Savings Account(use current balance)
$ / $ / $ / Savings Account(use current balance)
$ / $ / $ / Checking Account(use avg. six-month balance)
$ / $ / $ / Checking Account(use avg. six-month balance)
$ / $ / $ / Money Market(use current balance)
$ / $ / Cash on Hand or in Safety Deposit Box
$ / $ / $ / Debit Cards including Direct Express Card(not gift cards)
$ / $ / $ / Bonds
$ / $ / $ / Certificates of Deposit (CDs)
$ / $ / $ / Stock Portfolio
$ / $ / $ / $ / 401 Kor Other Retirement or Pension Fund
$ / $ / $ / $ / Trust Fund
$ / $ / $ / $ / Land Contract
$ / $ / $ / $ / Capital Investment
$ / $ / $ / $ / Life Insurance (Not Term Life)
$ / $ / $ / $ / Annuity
$ / $ / $ / $ / Equity in Real Estate
$ / $ / Personal property/investmentsuch as art, antique cars, etc.
$ / $ / $ / $ / Other
$ / $ / $ / $ / Other
Total Cash Value of all Assets / $ / Total Income from Assets / $

*Cash value is defined as market value minus the cost of converting the asset to cash, such as broker's fees, settlement costs, outstanding loans, early withdrawal penalties, etc.

Assets Disposed of For Less Than Fair Market Value

I hereby certify that during the previous two-year (24-month) period I have disposed of assets as indicated in the form below:

Asset Type / None / Date Disposed / Amount
Cash Contributions or Gifts (to Churches, Charities, Individuals, etc.) / $
Property sold for less than fair market value
(this identifies property that was given away or sold for substantially less than current real estate market would bear such as a Quit Claim) / $
Trust/Savings/Investment Accounts Opened for another person / $
Transfer of Assets for Free or For Less Than Market Value (for example, giving a child stock or mutual funds or setting up a trust for someone who does not live in the unit) / $
Other / $
PENALTIES FOR MISUSING THIS 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 **408 (a) (6), (7) and (8).

Under penalty of perjury, I/we certify that the information presented in this certification is true and accurate to the best of my/our knowledge. The undersigned further understand(s) that providing false representations herein constitutes an act of fraud. Providing false, misleading or incomplete information may result in the termination of the lease agreement.

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Page 1 of 2 Revised 3/2018