(*Adult 1)Last Name/First Name/Middle
(*Adult 2) Last Name/First Name/Middle
Last Name/First Name/Middle
The following information should be completed by the Head of Household. The information provided is confidential and kept on file at this agency for Federal funding only.
As a federally funded agency, the Office of Management and Budget (OMB) requires the collection of the following data on race, ethnicity, and income for statistical purposes, programs administrative reporting, and civil compliance reporting. IMB-defined ethnic and race categories are as follows:
Provide following information regarding the Client receiving the service:
I hereby certify that my application meets the HUD Time and Residence requirements as an eligible "household" because of one of the following:
I understand that any misrepresentation of information or failure to disclose information requested on this form may disqualify me from participation in the Healthy Homes Program. Anyone who knowingly or willfully makes or uses a document containing any false, fictitious, or fraudulent statement or entry may be criminally prosecuted and may incur civil administrative liability punishable by fine or imprisonment or both. WARNING: It is unlawful to provide false information to the government when applying for federal public benefit programs per the Program Fraud Civil Remedies Act of 1986, 31 U.S.C. §§ 3801-3812.
By signing below, I confirm that the information provided herein is true and accurate to the best of my knowledge.
By checking ?I agree,? you agree and acknowledge your electronic signature is valid and binding in the same force and effect as a handwritten signature.
This field is not part of the form submission.
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