OMB Control #2502-0581

Exp.(02/28/2019)

SupplementalandOptionalContactInformationforHUD-AssistedHousingApplicants

SUPPLEMENTTOAPPLICATIONFORFEDERALLYASSISTEDHOUSING

Thisformistobeprovidedtoeachapplicantforfederallyassistedhousing

Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application forhousing,thename,address,telephonenumber,andotherrelevantinformationofafamilymember,friend,orsocial,health,advocacy,orotherorganization.Thiscontactinformationisforthepurposeofidentifyingapersonororganizationthatmaybeabletohelpinresolvinganyissues that may arise during your tenancy or to assist in providing any special care or services you may require. You mayupdate,remove, or change the information you provide on this form at any time. You are not required to provide this contactinformation,butifyouchoosetodoso,pleaseincludetherelevantinformationonthisform.

ApplicantName:
MailingAddress:
TelephoneNo: / Cell PhoneNo:
Name of Additional Contact Person orOrganization:
Address:
TelephoneNo: / Cell PhoneNo:
E-Mail Address (ifapplicable):
Relationship toApplicant:
Reason for Contact: (Check all thatapply)
Emergency / Assist with RecertificationProcess
Unable to contactyou / Change in leaseterms
Termination of rentalassistance / Change in houserules
Eviction fromunit / Other:
Late payment ofrent
Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. Ifissues ariseduringyourtenancyorifyourequireanyservicesorspecialcare,wemaycontactthepersonororganizationyoulistedtoassistinresolvingthe issues or in providing any services or special care toyou.
ConfidentialityStatement:Theinformationprovidedonthisformisconfidentialandwillnotbedisclosedtoanyoneexceptaspermittedbytheapplicant or applicablelaw.
Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28,1992)requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact personororganization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equalopportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assistedhousing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibitiononage discrimination under the Age Discrimination Act of1975.

Checkthisboxifyouchoosenottoprovidethecontactinformation.

Signature ofApplicant / Date

TheinformationcollectionrequirementscontainedinthisformweresubmittedtotheOfficeofManagementandBudget(OMB)underthePaperworkReductionActof1995(44U.S.C.3501-3520).Thepublicreportingburdenisestimatedat15minutesperresponse,includingthetimeforreviewinginstructions,searchingexistingdatasources,gatheringandmaintainingthedataneeded,andcompletingandreviewingthecollectionofinformation. Section644oftheHousingand CommunityDevelopmentActof1992(42U.S.C.13604)imposedonHUDtheobligationtorequirehousingproviders participatinginHUD’sassistedhousingprogramstoprovideanyindividualorfamilyapplyingforoccupancyinHUD-assistedhousingwiththeoptiontoincludeintheapplicationforoccupancythename,address,telephonenumber,andotherrelevantinformationofa familymember,friend,orpersonassociatedwithasocial,health,advocacy,orsimilarorganization.Theobjectiveofprovidingsuchinformationistofacilitatecontactbythehousingproviderwiththepersonororganizationidentifiedbythetenanttoassistinprovidinganydeliveryofservicesorspecialcaretothetenantandassistwithresolvinganytenancyissuesarisingduringthetenancyofsuchtenant.Thissupplementalapplicationinformationistobemaintainedbythehousingproviderandmaintainedasconfidentialinformation.

ProvidingtheinformationisbasictotheoperationsoftheHUDAssisted-HousingProgramandisvoluntary.Itsupportsstatutoryrequirementsandprogramandmanagementcontrolsthatpreventfraud,wasteand mismanagement.InaccordancewiththePaperworkReductionAct,anagencymaynotconductorsponsor,andapersonisnotrequiredtorespondto,acollectionofinformation,unlessthecollectiondisplaysacurrentlyvalidOMBcontrolnumber.

PrivacyStatement:PublicLaw102-550,authorizestheDepartmentofHousingandUrbanDevelopment(HUD)tocollectalltheinformation(excepttheSocialSecurityNumber(SSN))whichwillbeusedbyHUDtoprotectdisbursementdatafromfraudulentactions.

Form HUD- 92006(05/09)

R-60 HUD-92006 Optional Contact Person or OrganizationMarch 2018