Please Read This Statement Carefully Before Signing This Verification Form

STATEMENT OF MARITAL SEPARATION

Property: Date:

Applicant/Resident: Unit:

Please read this statement carefully before signing this verification form:

PENALTIES FOR MISUSING THIS CONSENT: Title 18, Section 1001 of the U.S. Code state 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, Rural Housing Services (RHS) and any owner (or any employee of HUD, the PHA, 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 my be subject to a misdemeanor and fined not more than $5000. Any applicant or participant affected by negligent disclosure or information may bring civil action for damages, and set other relief, as may be appropriate, against the officer or employee of HUD, the PHA, RHS or the Owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the Social Security Number are contained in the SocialSecurity Act of 42 U.S.C. 208 (f) and (h). Violation of these provisions are cited as violations of 42 U.S.C. 408 (f), (g) and (h).

Please complete the questions below as they apply to your circumstances:

1. / Are you separated, but not divorced from your spouse? / Yes
No
2. / Do you own a home and/or other assets jointly with your spouse? / Yes
No / If “yes” please list:
3. / Do you have “access” to the home and/or other assets? / Yes
No / If “yes” please attach ownership documentation for home/assets.
If “no” please explain: ______
______
4. / Are you legally separated from your spouse? / Yes
No / If “yes” please attach a copy of legal separation agreement and skip questions 5 and 6 below.
If “no” please answer questions 5 and 6 below.
5. / My reason for not pursuing legal separation is: ______
______
6. / My future plan for pursuing legal action is: ______
______
7. / If you have dependents, do you have 50% or more joint custody with your spouse? / Yes
No / If “yes” please attach a copy of the custody agreement.
If “no” please explain: ______
______
8. / I currently receive $______per ______(month/week) for child support from my spouse.
Please list all children receiving support: ______
9. / I currently receive $______per ______(month/week) for alimony, split pension, etc. from my spouse.

SIGNATURE(S): I understand that part of my eligibility for housing is based on my current household size (composition) and gross income. My spouse will not be part of my household. If this circumstance should change, I will immediately contact the Property Manager to update my household circumstances and current resident certification.

Applicant/Resident SignatureDatePrinted Name

Owner/Owner’s Agent SignatureDatePrinted Name

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