Rental Assistance Recertification Packet

Application/Participant Certification

You must use the correct legal name for each member of your household as it appears on their Social Security card. All adult members of the household must sign where indicated certifying the information pertaining to them. Community Development Corporation of Long Island’s (“CDCLI”) policy states no adult person(s) other than those listed on the lease and applications shall live/stay in the unit other than on a temporary basis (not to exceed 15 consecutive or 60 calendar days per year). This is to insure that the total tenant payment is accurately based on the total monthly income of that household unit. Before adding a household member, you must get approval in writing from both the landlord and this agency. A guest may not stay with a family more than 60 days per calendar year. If a person continues to live in your unit without our approval, CDCLI may begin termination proceedings against you. In addition, should a household member move out of your unit, you must report this information to CDCLI in writing within two weeks of their move out.

Head of Household

Full Legal Name

Date of Birth (mm/dd/yyyy)

Social Security Number

Full-time student?

Birthplace

Adult Household Member

Full Legal Name

Date of Birth (mm/dd/yyyy)

Social Security Number

Full-time student?

Birthplace

Relationship to Head of Household

Child Household Member

Full Legal Name (as it appears on Social Security Card)

Date of Birth (mm/dd/yyyy)

Social Security Number

Full-time student?

Birthplace

Relationship to Head of Household

Household Income

All household income includes everyone (husband, wife, children, other) who currently lives in your housing unit or assists in paying your rent expenses. List all money earned or received by everyone living in your household. This includes money from wages, self-employment, child support, contributions, Social Security, disability payments (SSI), Workman's Compensation, retirement benefits, TANF, Veteran benefits, rental property income, stock dividends, income from any bank accounts, and all other sources.

CDCLI MUST be notified of all income changes within 2 weeks.

Income Source #1

Household Member Name

Employer

Total Weekly Wages

Public Assistance

Monthly Child Support

Social Security Benefits

Unemployment benefits

Other income sources

Applicant Information Continued

Assets

Do you or any household members own or have an interest in any real estate, boat, or mobile home?

Have you or any household members sold any real estate over the last 2 years?

Do you or any household members own any stocks or bonds?

Do you or any household members have a checking account?

Do you or any household members have a savings account?

Bank Account Information

Account type (savings or checking)

Account number

Bank name

Account number

Amount in account (in dollars)

Automobile Information

Model

Year

License Plate Number

Asset Disclaimer

Has any member disposed of asset for less than fair market value during the two years preceding the effective date of the certification or recertification?

If yes, what type of asset was disposed of?

Date disposed of?

Amount received for asset

Fair market value at the time of disposition

Does anyone outside of your household pay for your any of your bills or give you money?

Have you or any other adult members ever used any name(s) or Social Security number(s) other than the ones you are currently using?

Have you or any other member lived in assisted housing?

Have you or any other member in the household committed any fraud in a federally assisted housing program or requested to repay money for knowingly misrepresenting information for such housing programs?

Is any member of your household subject to a lifetime registration requirement under a state sex offender registration program?

Tenant Certification

I do hereby solemnly swear or attest that all of the information listed about me is true and correct. I also understand that all changes in income of any member of the household as well as any changes in members of the household must be reported to CDCLI in writing within 2 weeks.

As a signature, please print your name in the space(s) below

Electronic Signature (printed name) of Head of Household

Adult Member of Household Electronic Signature

Electronic Signature (printed name) of Household Member

Relationship to Head of Household

WARNING: Title 18 Section 1001 of the United States code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any Department or Agency of the United States.

Citizenship Declaration

Family Member

First Name

MI

Last Name

Date of Birth

Citizenship status (select one)

Print Signature of Adult or parent/guardian on behalf of persons under 18 years of age

Head of Household Electronic Signature

As head of household, I hereby certify under penalty of perjury that to the best of my knowledge, all the members of my household are listed above and have correctly indicated their citizenship or immigration status.

Date

U.S. Department of Housing and Urban Development Office of Public and Indian Housing DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS

Paperwork Reduction Notice: Public reporting burden for this collection of information is estimated to average 7 minutes per response. This includes the time for respondents to read the document and certify, and any recordkeeping burden. This information will be used in the processing of a tenancy. Response to this request for information is required to receive benefits. The agency may not collect this information, and you are not required to complete this form, unless it displays

a currently valid OMB control number. The OMB Number is 2577‐0266, and expires 10/31/2019.

NOTICE TO APPLICANTS AND PARTICIPANTS OF THE FOLLOWING HUD RENTAL ASSISTANCE PROGRAMS:

Public Housing (24 CFR 960)

Section 8 Housing Choice Voucher, including the Disaster Housing Assistance Program (24 CFR 982)

Section 8 Moderate Rehabilitation (24 CFR 882)

Project-Based Voucher (24 CFR 983)

The U.S. Department of Housing and Urban Development maintains a national repository of debts owed to Public Housing Agencies (PHAs) or Section 8 landlords and adverse information of former participants who have voluntarily or involuntarily terminated participation in one of the above-listed HUD rental assistance programs. This information is maintained within HUD’s Enterprise Income Verification (EIV) system, which is used by Public Housing Agencies (PHAs) and their management agents to verify employment and income information of program participants, as well as, to reduce administrative and rental assistance payment errors. The EIV system is designed to assist PHAs and HUD in ensuring that families are eligible to participate in HUD rental assistance programs and determining the correct amount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUD regulations at 24 CFR 5.233.

HUD requires PHAs, which administers the above-listed rental housing programs, to report certain information at the conclusion of your participation in a HUD rental assistance program. This notice provides you with information on what information the PHA is required to provide HUD, who will have access to this information, how this information is used and your rights. PHAs are required to provide this notice to all applicants and program participants and you are required to acknowledge receipt of this notice by signing page 2. Each adult household member must sign this form.

What information about you and your tenancy does HUD collect from the PHA?

The following information is collected about each member of your household (family composition): full name, date of birth, and Social Security Number.

The following adverse information is collected once your participation in the housing program has ended, whether you voluntarily or involuntarily move out of an assisted unit:

1. Amount of any balance you owe the PHA or Section 8 landlord (up to $500,000) and explanation for balance owed (i.e. unpaid rent, retroactive rent (due to unreported income and/ or change in family composition) or other charges such as damages, utility charges, etc.); and

2. Whether or not you have entered into a repayment agreement for the amount that you owe the PHA; and

3. Whether or not you have defaulted on a repayment agreement; and

4. Whether or not the PHA has obtained a judgment against you; and

5. Whether or not you have filed for bankruptcy; and

6. The negative reason(s) for your end of participation or any negative status (i.e., abandoned unit, fraud, lease

violations, criminal activity, etc.) as of the end of participation date.

Who will have access to the information collected?

This information will be available to HUD employees, PHA employees, and contractors of HUD and PHAs.

How will this information be used?

PHAs will have access to this information during the time of application for rental assistance and reexamination of family income and composition for existing participants. PHAs will be able to access this information to determine a family’s suitability for initial or continued rental assistance, and avoid providing limited Federal housing assistance to

families who have previously been unable to comply with HUD program requirements. If the reported information is accurate, a PHA may terminate your current rental assistance and deny your future request for HUD rental assistance, subject to PHA policy.

How long is the debt owed and termination information maintained in EIV?

Debt owed and termination information will be maintained in EIV for a period of up to ten (10) years from the end of participation date or such other period consistent with State Law.

What are my rights?

In accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to its implementation of the Federal Privacy Act of 1974 (24 CFR Part 16), you have the following rights:

1. To have access to your records maintained by HUD, subject to 24 CFR Part 16.

2. To have an administrative review of HUD’s initial denial of your request to have access to your records maintained by HUD.

3. To have incorrect information in your record corrected upon written request.

4. To file an appeal request of an initial adverse determination on correction or amendment of record request within 30 calendar days after the issuance of the written denial.

5. To have your record disclosed to a third party upon receipt of your written and signed request.

What do I do if I dispute the debt or termination information reported about me?

If you disagree with the reported information, you should contact in writing the PHA who has reported this information about you. The PHA’s name, address, and telephone numbers are listed on the Debts Owed and Termination Report.

You have a right to request and obtain a copy of this report from the PHA. Inform the PHA why you dispute the information and provide any documentation that supports your dispute. HUD's record retention policies at 24 CFR Part 908 and 24 CFR Part 982 provide that the PHA may destroy your records three years from the date your participation in the program ends. To ensure the availability of your records, disputes of the original debt or termination information must be made within three years from the end of participation date; otherwise the debt and termination information will be presumed correct. Only the PHA who reported the adverse information about you can delete or correct your record.

Your filing of bankruptcy will not result in the removal of debt owed or termination information from HUD’s EIV system. However, if you have included this debt in your bankruptcy filing and/or this debt has been discharged by the bankruptcy court, your record will be updated to include the bankruptcy indicator, when you provide the PHA with documentation of your bankruptcy status.

The PHA will notify you in writing of its action regarding your dispute within 30 days of receiving your written dispute.

If the PHA determines that the disputed information is incorrect, the PHA will update or delete the record. If the PHA determines that the disputed information is correct, the PHA will provide an explanation as to why the information is correct.

This Notice was provided by the below-listed PHA:

Community Development Corporation of LI

2100 Middle Country Road

Centereach, New York 11720

Privacy Act Notice

HUD and HA Consent to Obtain Information

Head of Household Electronic Signature

Head of Household First Name

Head of Household MI

Head of Household Last Name

Head of Household Social Security Number

Date

Other Family Member Electronic Signature

First Name

MI

Last Name

Date

Relationship to Head of Household

Consent for Release of Information

Head of Household Electronic Signature

Head of Household First Name

Head of Household MI

Head of Household Last Name

Date

Other Family Member Electronic Signature

First Name

MI

Last Name

Date

Relationship to Head of Household

Supplement to Application for Federally Assisted Housing

This form is to be provided to each applicant for federally assisted housing.

Applicant First Name

Applicant Last Name

Phone

Cell Phone

Mailing Address Line 1

Mailing Address Line 2

City

Country

State

Postal Code

Do you choose to provide contact information for an additional contact?

Additional Contact First Name

Additional Contact Last Name

Additional Contact Phone

Additional Contact Cell Phone

Mailing Address Line 1

Mailing Address Line 2

City

Country

State

Postal Code

Relationship to Applicant

U.S. Department of Housing and Urban Development
Office of Public and Indian Housing (PIH)

What You Should Know About EIV

A Guide for Applicants & Tenants of

Public Housing & Section 8 Programs

What is EIV?

The Enterprise Income Verification (EIV) system is a

web-based computer system that contains

employment and income information of individuals

who participate in HUD rental assistance programs.

All Public Housing Agencies (PHAs) are required to

use HUD’s EIV system.

What information is in EIV and where does it

come from?

HUD obtains information about you from your local

PHA, the Social Security Administration (SSA), and

U.S. Department of Health and Human Services

(HHS). HHS provides HUD with wage and employment

information as reported by employers; and

unemployment compensation information as reported

by the State Workforce Agency (SWA). SSA provides HUD with death, Social Security (SS) and Supplemental Security Income (SSI) information.

What is the EIV information used for?

Primarily, the information is used by PHAs (and

management agents hired by PHAs) for the following

purposes to:

1. Confirm your name, date of birth (DOB), and

Social Security Number (SSN) with SSA.

2. Verify your reported income sources and

amounts.

3. Confirm your participation in only one HUD

rental assistance program.

4. Confirm if you owe an outstanding debt to any

PHA.

5. Confirm any negative status if you moved out

of a subsidized unit (in the past) under the

Public Housing or Section 8 program.

6. Follow up with you, other adult household

members, or your listed emergency contact

regarding deceased household members.

EIV will alert your PHA if you or anyone in your

household has used a false SSN, failed to report

complete and accurate income information, or

is receiving rental assistance at another address.

Remember, you may receive rental assistance at

only one home!

EIV will also alert PHAs if you owe an outstanding debt

to any PHA (in any state or U.S. territory) and any

negative status when you voluntarily or involuntarily

moved out of a subsidized unit under the Public

Housing or Section 8 program. This information is used

to determine your eligibility for rental assistance at the

time of application.

The information in EIV is also used by HUD, HUD’s

Office of Inspector General (OIG), and auditors to

ensure that your family and PHAs comply with HUD

rules.

Overall, the purpose of EIV is to identify and prevent

fraud within HUD rental assistance programs, so that

limited taxpayer’s dollars can assist as many eligible

families as possible. EIV will help to improve the

integrity of HUD rental assistance programs.

Is my consent required in order for information

to be obtained about me?

Yes, your consent is required in order for HUD or the

PHA to obtain information about you. By law, you are

required to sign one or more consent forms. When

you sign a form HUD-9886 (Federal Privacy Act

Notice and Authorization for Release of Information) or

a PHA consent form (which meets HUD standards),

you are giving HUD and the PHA your consent for

them to obtain information about you for the purpose

of determining your eligibility and amount of rental

assistance. The information collected about you will be

used only to determine your eligibility for the program,

unless you consent in writing to authorize additional

uses of the information by the PHA.

Note: If you or any of your adult household

members refuse to sign a consent form, your

request for initial or continued rental assistance

may be denied. You may also be terminated from

the HUD rental assistance program.

What are my responsibilities?

As a tenant (participant) of a HUD rental assistance

program, you and each adult household member must

disclose complete and accurate information to the

PHA, including full name, SSN, and DOB; income

information; and certify that your reported household

composition (household members), income, and

expense information is true to the best of your

knowledge. Remember, you must notify your PHA if a household member dies or moves out. You must also obtain the PHA’s approval to allow additional family members or friends to move in your home prior to them moving in.

What are the penalties for providing false

information?

Knowingly providing false, inaccurate, or incomplete

information is FRAUD and a CRIME.

If you commit fraud, you and your family may be

subject to any of the following penalties:

1. Eviction

2. Termination of assistance

3. Repayment of rent that you should have paid

had you reported your income correctly

4. Prohibited from receiving future rental

assistance for a period of up to 10 years

5. Prosecution by the local, state, or Federal

prosecutor, which may result in you being

fined up to $10,000 and/or serving time in jail.

Protect yourself by following HUD reporting

requirements. When completing applications and

reexaminations, you must include all sources of

income you or any member of your household

receives.

If you have any questions on whether money received

should be counted as income or how your rent is

determined, ask your PHA. When changes occur in

your household income, contact your PHA

immediately to determine if this will affect your rental

assistance.

What do I do if the EIV information is

incorrect?

Sometimes the source of EIV information may make

an error when submitting or reporting information about

you. If you do not agree with the EIV information, let

your PHA know.

If necessary, your PHA will contact the source of the

information directly to verify disputed income

information. Below are the procedures you and the

PHA should follow regarding incorrect EIV information.

Debts owed to PHAs and termination information

reported in EIV originates from the PHA who provided

you assistance in the past. If you dispute this

information, contact your former PHA directly in writing

to dispute this information and provide any

documentation that supports your dispute. If the PHA

determines that the disputed information is incorrect,

the PHA will update or delete the record from EIV.

Employment and wage information reported in EIV

originates from the employer. If you dispute this

information, contact the employer in writing to dispute

and request correction of the disputed employment

and/or wage information. Provide your PHA with a

copy of the letter that you sent to the employer. If you

are unable to get the employer to correct the

information, you should contact the SWA for

assistance.

Unemployment benefit information reported in EIV

originates from the SWA. If you dispute this

information, contact the SWA in writing to dispute and

request correction of the disputed unemployment

benefit information. Provide your PHA with a copy of

the letter that you sent to the SWA.

Death, SS and SSI benefit information reported in

EIV originates from the SSA. If you dispute this

information, contact the SSA at (800) 772–1213, or

visit their website at: www.socialsecurity.gov. You

may need to visit your local SSA office to have

disputed death information corrected.

Additional Verification. The PHA, with your consent,

may submit a third party verification form to the

provider (or reporter) of your income for completion

and submission to the PHA.

You may also provide the PHA with third party

documents (i.e. pay stubs, benefit award letters, bank

statements, etc.) which you may have in your

possession.

Identity Theft. Unknown EIV information to you can

be a sign of identity theft. Sometimes someone else

may use your SSN, either on purpose or by accident.

So, if you suspect someone is using your SSN, you

should check your Social Security records to ensure

your income is calculated correctly (call SSA at (800)

772-1213); file an identity theft complaint with your

local police department or the Federal Trade

Commission (call FTC at (877) 438-4338, or you may

visit their website at: http://www.ftc.gov). Provide your

PHA with a copy of your identity theft complaint.

Where can I obtain more information on EIV

and the income verification process?

Your PHA can provide you with additional information

on EIV and the income verification process. You may

also read more about EIV and the income verification

process on HUD’s Public and Indian Housing EIV web

pages at: http://www.hud.gov/offices/pih/programs/ph/rhiip/uiv.cfm.

The information in this Guide pertains to

applicants and participants (tenants) of the

following HUD-PIH rental assistance programs:

1. Public Housing (24 CFR 960); and

2. Section 8 Housing Choice Voucher (HCV),

(24 CFR 982); and

3. Section 8 Moderate Rehabilitation (24 CFR

882); and

4. Project-Based Voucher (24 CFR 983)

My electronic signature below is confirmation that I have received this Guide.

Bank and School Verification Documents

Please upload your verification of bank document here.

Please upload your verification of school status here,

ALL adult family members living in household MUST sign

In order for you to receive and continue to receive Housing Choice Voucher (HCV) rental assistance, you and your entire household MUST fulfill your obligations to the COMMUNITY DEVELOPMENT CORP. OF LONG ISLAND (CDCLI) Housing Choice Voucher (HCV) Program. If you fail to fulfill your obligations, your rental assistance may be terminated.

IN ORDER TO MEET YOUR FAMILY OBLIGATIONS, YOU MUST:

 Complete a determination of eligibility annually.

 Supply any and all information that CDCLI requests to determine eligibility, including evidence of citizenship or eligible immigration status, verification of social security numbers, consent forms for obtaining necessary information, and any other information requested.

 Supply information that is true and complete.

 Report any and all changes in income or assets in writing to CDCLI within two (2) weeks of the change.

 Report any and all changes in Household Composition in writing within two (2) weeks of the change to CDCLI.

 Request in writing and receive written approval from CDCLI before any other person moves into your household.

 Notify CDCLI in writing within two (2) weeks if any family member no longer lives in the unit.

 Notify CDCLI in writing if any household member is going to be away from the unit for an extended time period.

 Request permission for absences that will be longer than 30 days.

 Allow CDCLI to inspect the unit at reasonable times and after reasonable notice. Any unit participating in the HCV program MUST meet Housing Quality Standards at all times.

 Only reside in the assisted unit.

 Immediately give CDCLI a copy of any owner eviction notice. In addition, provide copies of all court orders.

 Pay your utility bills and supply appliances that you are required to supply under the lease and HAP contract.

 Pay your share of the rent in a timely manner and pay only the rent specified by CDCLI. Your portion of the rent is calculated by CDCLI and is stated in your Rent Adjustment Letter. Pay no more than stated.

MOVES

After the first term of the lease, you may be able to continue to receive assistance in a new unit if the following conditions are met. Families

are not permitted to move more than once in a 12-month period (unless beyond your control).

IF YOU WISH TO MOVE, YOU MUST:

 Notify CDCLI if you intend to move.

 Give your landlord a 30-day written notice.

 Provide a copy of the notice to CDCLI and complete a copy of the Notice to Vacate form.

 Ensure that all rental payments to the landlord are up-to-date and re-payment agreement monies owed to CDCLI are paid in full.

 Ensure that all tenant-related damages to the unit are repaired before you move.

You CANNOT move into a new unit until CDCLI approves it. CDCLI will conduct an inspection to ensure all Housing Quality Standards

required by HUD are met. CDCLI will also ensure that the rent is reasonable and affordable and the owner is eligible to participate in the

HCV program.

You are responsible if the housing unit fails the CDCLI inspection for any of the following reasons:

 You fail to pay for any utilities that your family is responsible for according to the terms of the lease.

 You fail to provide and maintain any appliances that the family provides under the lease.

 Any member of the household or guest damages the dwelling unit or premises beyond normal wear and tear.

YOU AND ANY MEMBER OF YOUR HOUSEHOLD MUST NOT:

 Own or have any interest in the unit.

 Commit fraud, bribery, or any other corrupt or criminal act in connection with the HCV program.

 Participate in illegal drug or violent criminal activity, or any other criminal activity.

 Sublease, sublet, assign the lease, or transfer the unit to any other party.

 Commit any serious or repeated violation of the lease.

 Receive HCV assistance while receiving another housing subsidy, for the same unit or a different unit under any other Federal, State, or local housing assistance program.

 Abuse drugs or alcohol in any way that threatens the health, safety or right to peaceful enjoyment of other tenants in the immediate vicinity of the premises.

GROUNDS FOR DENIAL OR TERMINATION OF ASSISTANCE

CDCLI may at any time deny program assistance for an applicant, or terminate program assistance for a participant for the following:

 If the family violates any family obligation under the HCV program (see first page)

 If any member of the family is subject to lifetime registration under a state sex offender registration program

 If any member of the family has ever been evicted from public housing

 If any agency has ever terminated assistance for cause under the voucher program for any member of the family

 If the family currently owes rent or other amounts to CDCLI or to another agency in connection with the HCV Program or public housing assistance under the Housing Act of 1937

 If the family has not reimbursed any agency for amounts paid to an owner under a HAP Contract for rent, damages to the unit, or other amounts owed by the family under the lease

 If the family breaches an agreement with CDCLI to pay amounts owed to this office, or amounts paid to an owner by this office

 If the family has engaged in or threatened abusive or violent behavior toward CDCLI personnel

 If the family is guilty of abuse or fraud (fraud is a criminal offense)

 If the family refuses to supply any certification, release of information or documentation which CDCLI or HUD determines to be necessary for the administration of the program

 If the family vacates the dwelling unit without proper notice to CDCLI

 If the family does not use the dwelling as its principal place of residence

 If the family engages in drug-related activity or violent criminal activity, including criminal activity by any family member

Adults of Household Signatures

I/We have read and understand the CDCLI HCV Program Family Obligations, and I/we agree to abide by these obligations.

Electronic Signature of Head of Household

Date

Adult Member of Household Electronic Signature

Electronic Signature (printed name) of Household Member

Date

Relationship to Head of Household

Participant/Applicant Signature

Dear Applicant/Participant:

Beginning January 2017 Community Development Corporation of Long Island (“CDCLI”) must provide each applicant and participant with the following Violence Against Woman Act (VAWA) Appendices:

VAWA Appendix A – Notice of Occupancy Rights under the Violence Against Women Act, form HUD -5380

VAWA Appendix B – Model Emergency Transfer Plan for Victims of Domestic Violence, Dating Violence, Sexual Assault, or Stalking, form HUD-5381

VAWA Appendix C – Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking and Alternate Documentation, form HUD-5382

VAWA Appendix D – Emergency Transfer Request for Certain Victims of Domestic Violence, Dating Violence, Sexual Assault, or Stalking, form HUD-5383

These forms are for you to keep and refer to if necessary. Please note that although the statutory name references women, VAWA rights and protections apply to all victims of domestic violence, dating violence, sexual assault or stalking.

All Applicants/Participants must acknowledge receipt of these forms by signing below and returning this top form to your Housing Specialist.

Electronic Signature of Head of Household

Date

RULES OF THE HOUSING CHOICE VOUCHER PROGRAM

It is the responsibility of the head of household (that's you) to report to Community Development Corporation of Long Island (“CDCLI”) all household income and family composition changes in writing within two (2) weeks of the change.

HOUSEHOLD INCOME:

All household income includes everyone (husband, wife, children, other) who currently lives in your housing unit, or assists in paying your expenses.

FAMILY COMPOSITION:

Before adding a household member, you must get approval in writing from both the landlord and CDCLI. A guest staying in your unit may not exceed 15 consecutive or 60 calendar days per year. If a person continues to live in your unit without our approval, CDCLI may begin termination proceedings against you.

In addition, should a household member move out of your unit, you must report this information to CDCLI in writing and provide supportive documentation.

I have read the above and understand what I have read.

Electronic Signature of Head of Household

Date

ADDITIONAL ADULT LIVING IN UNIT

Community Development Corporation of Long Island’s (“CDCLI”) policy states no adult person(s) other than those listed on the lease and/or application shall live or stay in the unit other than on a temporary basis (may not exceed 15 consecutive or 60 calendar days per year). This is to ensure that the total tenant payment is accurately based on the total monthly income of that household unit.

To add someone to the household, you must obtain written permission from CDCLI and the landlord in advance of anyone moving into the unit.

If an adult other than those named on the lease is in the unit for more than fifteen (15) consecutive or sixty (60) calendar days per year, I agree to contact CDCLI immediately. I realize that failure to do this could result in repayment of the rent and possible theft and fraud charges under state and federal law.

I understand the above statement. There is no other adult living or staying in the unit now other than those whose name is on the application and/or lease.

Electronic Signature of Head of Household

Date