SECTION 8 OFFICE

700 ANDOVER PARK W, SUITE A, TUKWILA, WA, 98188-3322 PHONE:

(206) 214-1300 FAX: (206) 243-5927

Please complete the enclosed KCHA packet with black or blue pen only and provide verification
as applicable.
INCOME

z PUBLIC ASSISTANCE: SECTION 8 OFFICE WILL REQUEST VERIFICATION DIRECTLY FROM DSHS.

z EMPLOYMENT VERIFICATION: If employed, please provide name, address, and phone number of employer for head of
household, spouse and all dependent members age 21 and over.

z SELF-EMPLOYMENT: Yearly or quarterly tax records, a copy of business license and copy of profit/loss statement plus receipts.

z UNEMPLOYMENT: SECTION 8 OFFICE WILL REQUEST VERIFICATION DIRECTLY FROM EMPLOYMENT SECURITY OFFICE.

z CHILD SUPPORT: Notarized letter from paying parent indicating direct payment amount, or copy of divorce decree indicating
child support. SECTION 8 OFFICE WILL REQUEST VERIFICATIONS FROM WASHINGTON STATE OFFICE OF SUPPORT
ENFORCEMENT.

z PENSION, ANNUITY, VETERANS BENEFITS, L & I, ALIMONY: Copy of current Award Letter. z OTHER INCOME: Gifts of Support or

income not mentioned above, verification must be provided.

z SSI/SOCIAL SECURITY BENEFITS: PLEASE PROVIDE A COPY OF YOUR AWARD LETTER OR CALL 1-800-772-1213 OR GO TO
http://secure.ssa.gov/apps6z/isss/main.html

z BANK ACCOUNTS/ASSETS: If all assets combined total $50,000 or more, verification must be supplied. This includes savings,
checking, stocks, bonds, property, IRA's, mutual funds, annuities, trusts, inheritances, settlements.

ALLOWANCES

z FULL OR PART TIME STUDENTS STATUS: For dependent students and family members over 21 years of age. Current
enrollment and financial aid information from registrar or admissions officer.

z MEDICAL DEDUCTIONS (FOR EASY RENT HOUSEHOLDS IN WHICH HEAD OR SPOUSE IS AT LEAST 62 OR A PERSON WITH
DISABILITIES): Easy rent households must have over $2,500 to be eligible for deduction. Printout from pharmacy, or receipts
for medications or medical expenses paid in the last 12 months. We cannot use unpaid medical bills. Verification of attendant
care and/or auxiliary apparatus cost which allows family members to be employed.

z CHILD CARE: For "WIN Rent" program families only. For families with children under the age of 13, a deduction may be
allowed if the expenses are $2,500 or greater, AND the care enables the parent(s) to be gainfully employed or to further their
education.
REQUIRED DOCUMENTS FOR INITIAL APPLICATION OR AS APPLICABLE

z Submit copies of Social Security Cards for all family members, Photo I.D. for adult household members and INS
verification when required.
 OFFICE USE ONLY form
FORM #: 849
HOUSEHOLD ID:
KCHA 848 05/02/2018 TICKLER #:
SECTION 8 OFFICE
700 ANDOVER PARK W, SUITE A, TUKWILA, WA, 98188-3322
EFFECTIVE DATE:
PHONE: (206) 214-1300 FAX: (206) 243-5927

CERTIFICATION FORM PART 1.

TENANT/APPLICANT INFORMATION
(ALL LINES MUST BE COMPLETED. ENTER "N/A" IF IT DOES NOT APPLY)
NAME: HOME PHONE:

MARITAL STATUS: SINGLE MARRIED

OTHER:_______________________________

MAIDEN NAME, NICKNAME, OR ALIAS (if applicable):

ADDRESS: WORK PHONE:

CITY, STATE, ZIP: CELL PHONE:

EMAIL ADDRESS:

The following information is being requested to comply with Equal Opportunity requirements and will not affect your housing:

Primary Language: Translation Needed: YES NO

EMERGENCY CONTACTS: Please list two people we may contact if you are not available
NAME: NAME:
PHONE NO.:PHONE
NO.:
EMAIL:EMAIL:
RELATIONSHIP: RELATIONSHIP:
Do you intend to move to a different unit? YES

NO (If yes, please contact the Section 8 Office regarding moving procedures.)
Senior Housing Specialist at the Section 8 office.
If you have been in your unit for 12 months or more, you can move after providing proper written notice to your present landlord. Portability allows you to move to a different housing
jurisdiction anywhere in the country where a Section 8 program exists. More information about portability can be found at the KCHA website (www.kcha.org) or you can contact your

PART 2. HOUSEHOLD INFORMATION

A. Please list YOURSELF and ALL PERSONS living in the assisted unit (list additional members on a separate page). Do not list family
members who reside elsewhere during the school year. When completing "RACE", please use the following numbering system: 1-
CAUCASIAN; 2-AFRICAN AMERICAN; 3-NATIVE AMERICAN; 4-ASIAN; 5-PACIFIC ISLANDER; 6-HISPANIC
MBR RELATION BIRTH BIRTH SOCIAL
LAST NAME FIRST NAME MI AGE SEX RACE
# TO HEAD DATE PLACE SECURITY #
1 Head
2

REV 08-12-2019 PAGE 1 OF 3 FORM # 849

 3
4
5
6
7
List all persons who may move in or have moved out since your last recertification review
(e.g. deaths, marriages, permanent placement in nursing homes, incarceration, etc.).
FULL NAME RELATIONSHIP DATE OF MOVE REASON

I understand that any additional family member may not be added to the lease until the request has been reviewed and approved by the Housing
Authority and the Landlord. Please provide KCHA notice from your landlord of lease approval for the new member. If a member has moved out of your
unit, please provide documentation of their new address (e.g. lease, utility bill, drivers license, etc.).

B. Does anyone live with you who is not listed above? YES NO (If yes, please list their name(s) and explain:
) Please answer the following questions by placing a check(‫ )ط‬in the correct box: (all questions must be
answered) YES NO
(1) Head of Household or Spouse is Disabled
(2) Other Family Member is Disabled. If YES, please list their name(s):

(3) Is a reasonable accommodation based on disability necessary? If so, please indicate below.
Live-In Aide Additional Bedroom Rent Exception Hearing Impaired Smoke Detector Other (4)
Have you or any other family member listed on your application now or ever lived in Public Housing, Section 8
Assisted or any other form of government subsidized housing program? If YES, was your rental assistance ever
terminated for program violations? Please explain:

(5) Do you or any member of your household have a criminal record within the last three years? A criminal
history background check may be run on you and your household members. If YES, please list any criminal
history which will appear on your records within the past three years and where it occurred:

(6) Are there any children living in the household age six or under with an Elevated Lead Blood Level? If YES,
please list their name(s):

A Lead-Based Paint Brochure titled "Protect Your Family From Lead in Your Home" is available by request.
Additional information regarding lead paint can be found on the KCHA website (www.kcha.org)(The Housing Authority
provides this form to you at your initial housing.)

REV 08-12-2019 PAGE 2 OF 3 FORM # 849

 (7) Do any household members age 18 and over attend school? If YES, please list below. Use additional sheets if
necessary. For each student please supply: all Financial Aid letters and proof of the amount of tuition from
the school (if applicable).

* Child support includes regular contributions received from any source for a dependent.
B. On the chart below please list ALL sources of income received in the household. Please list any additional information on a separate
page.
GROSS AMOUNT OF
NAME OF HOUSEHOLD MEMBER SOURCE OF INCOME PER HOUR PER WEEK PER MONTH ANNUALLY
INCOME

C. Please complete employer information. Use additional sheets if necessary:

PERSON EMPLOYED PERSON EMPLOYED
EMPLOYER'S NAME EMPLOYER'S
NAME
ADDRESS ADDRESS
CITY, STATE, ZIP CITY, STATE, ZIP

REV 08-12-2019 PAGE 3 OF 3 FORM # 849

TELEPHONE # TELEPHONE #

D. Please answer the following questions by placing a check (‫ )ط‬in the correct box: (all questions must be YES NO
answered)
(1) Is any member of your household on a leave of absence from work due to a layoff, medical leave, maternity leave
or military leave? If YES, please list their name(s):
(2) Have you or any member(s) of your household ever served in the United States military? If YES, please list their
name(s):
(3) Does anyone else help you pay your bills or give you money? If YES, how much and provide their name and
contact information):

PART 4. ASSETS YES NO

$
(1)
MBR# Do TYPE
you have assets of $50,000 or more?
OF ASSETS BANKIfNAME
no, skip to (4) ACCOUNT # CURRENT BALANCE INTEREST RATE

(2) Do you have any checking accounts, saving accounts, money market funds, trusts, irrevocable trusts,
A. IRA/Keogh accounts, other retirement accounts, stocks/bonds, certificates of deposits, equity in rental YES NO
property or capital investments, other accounts, or cash held separately or jointly?:
(4) Do you presently own or lease any vehicles? YES NO If YES, please list (additional vehicles may be listed on
a separate page):
(3) Have you disposed of any assets for less than Fair Market Value in the past two years?:
Year/Make/Model: LICENSE # Monthly Payment $
Year/Make/Model: LICENSE # account, IRAs, Keogh accounts,
Please list any assets of $50,000 or more (including checking/savings MonthlyCDsPayment
stocks/bonds, dividends, homes,
mobile homes, or any form of real estate):

PART 5. FAMILY DEDUCTIONS

Please answer the following questions by placing a check (‫ )ط‬in the correct box: (all questions must be answered)
(1) CHILD CARE EXPENSES
Do you pay $2,500 or more per year in child care for a family member under the age of 13? If so, how much do
you pay per month? $_____________ (supporting documentation must be provided)

(2) MEDICAL EXPENSES

Is the Head of Household or Spouse over the age of 62 and/or disabled, and incurring out-of-pocket medical
expenses of $2,500 or more per year? If you select "YES", please provide receipts for ALL out-of-pocket medical
expenses for the past 12 months. (e.g., medical insurance premiums, co-pay, prescriptions etc.)

I/we hereby certify that this information is TRUE and ACCURATE. I/we understand that any misrepresentation on my/our part will result
in my/our housing assistance being terminated. I/we also understand I/we must report any changes in the above information to the
housing office in writing. I/we certify I/we have read and understand this information in accordance with federal housing regulations at
the time I/we am offered assistance.

Please complete all questions fully and sign where indicated. Failure to do so will result in paperwork being returned to you for further
information and will delay processing of any necessary changes.
REV 08-12-2019 PAGE 4 OF 3 FORM # 849
Signature of Head of Household Print Name Date

Signature of Spouse / Co-Tenant Print Name Date

After verification by the King County Housing Authority, the above information will be electronically submitted to the Department of Housing and Urban Development on Form HUD50058.
If you believe you have been discriminated against, you may call the Fair Housing and Equal Opportunity National toll-free hotline at 1-800-424-8590.

REV 08-12-2019 PAGE 5 OF 3 FORM # 849

 OFFICE USE ONLY
FORM #:
HOUSEHOLD ID:
TICKLER #:
EFFECTIVE DATE:
486
SECTION 8 OFFICE
700 ANDOVER PARK W, SUITE A, TUKWILA, WA, 98188-3322
PHONE: (206) 214-1300 FAX: (206) 243-5927

Authorization for Release of Information / Privacy Act Notice

I understand that to apply for or receive assistance through one of the King County Housing Authority’s (KCHA’s) housing assistance
programs, I must provide accurate and complete information regarding my income, family composition and circumstances. I hereby
authorize KCHA to request and obtain information in the categories or from sources listed below for the purpose of determining my
eligibility to receive housing assistance. In addition, I authorize KCHA to (1) provide a copy of this release to any person, business and/or
organization to which such requests are directed and I indemnify them from any harm for providing information in accordance with such
requests; and (2) to make inquiries regarding my income, family composition and circumstances from any source, including those I have
provided and those KCHA may identify during the course of processing my application for initial or continued program eligibility. I
understand that I will be given the opportunity to contest any negative determinations based on the information obtained.

Categories and Sources of Information Covered by this Authorization:

y Verification from employers, including information relating to y Expenses, including but not limited to childcare, medical and start and
end dates, wage and salary information, job handicapped assistance costs as needed to determine performance and unemployment
eligibility; eligibility, size of unit and appropriate rent and subsidy amounts;

y U.S. Social Security Administration and U.S. Internal Revenue y Immigration status, citizenship status, and legal identity
Service ( HUD only); verification;

y Rental history records and references, including but not limited y School registration for minor children and family members over to,
information about the ability to pay rent, the ability to live the age of 18 where required to establish program eligibility, independently,
take care of rental property, and get along well verify family composition or determine appropriate rent,
with neighbors; subsidy or size of unit;

y Non-residential references from individuals with whom a y Registration in educational or vocational training programs professional
relationship has been established, and references including information about participation, progress and from neighbors, community,
and relatives; completion of such programs;

y Criminal history, including fingerprint submission where necessary y Information from the Department of Licensing, law to effect
positive identification; enforcement agencies, courts and credit bureaus;

y Services provided by individuals or agencies which are relevant to y Information from utility companies and energy or water service
the ability to pay rent, take care of rental property, and get along districts, including information relating to consumption and
well with neighbors and community; billing records;

y Income and asset information from any source including but not y Verification of disability or handicap, if necessary for program
limited to the Department of Social and Health Services, Division eligibility (not including details of the actual disability or of Child
Support and information from State Wage Information handicap); Collection Agencies for all family members;

y Credit reports and/or tenant screening reports from private y Verification of need for reasonable accommodation, if screening
contractors; requested;

y Information regarding minor or foster children; y Information necessary to authenticate preference claims; y Outstanding debts to

other housing agencies.

REV 0
 OFFICE USE ONLY
FORM #:
3-01-2015 PAGE 1 OF 2 HOUSEHOLD ID: FORM # 486
Authority: This release of information is in lieu of the HUD-9886 Authorization for the
TICKLER #:
Release of Information/Privacy Act Notice.
EFFECTIVE DATE:
Who must sign the consent form: Each member of your household who is 18 years of
age or older must sign the consent form. Additional signatures must be obtained from new adult members joining the household
or whenever members of the household become 18 years of age.

Failure to sign consent form: Your failure to sign the consent form may result in the denial of eligibility or termination of assisted
housing benefits, or both. Denial of eligibility or termination of benefits is subject to KCHA’s grievance and Housing Choice Voucher
informal hearing procedures.

Purpose: In signing this consent form, you are authorizing HUD and the above-named HA to request income information from the
sources listed on the form. Information requested may include current or historical data determined necessary by HUD and/or
KCHA to verify your household’s income in order to ensure that you are eligible for assisted housing benefits and that these
benefits are set at the correct level. HUD and KCHA may participate in computer matching programs with these sources in order to
verify your eligibility and level of benefits. This consent becomes effective once signed. This consent expires 40 months after it is
signed.
OFFICE USE ONLY
HOH SSN - last 4 #:
SIGNATURES Subsidy/Unit #:

Head of Household (printed name) Signature Date

Co-Head, Spouse, Partner, or Other Adult (printed name) Signature Date

Other Adult – Age 18 or older (printed name) Signature Date

Privacy Act Notice:

Other Adult – Age 18 or older (printed name) Signature DateAuthority: The

Department of
Housing and Urban
Other Adult – Age 18 or older (printed name) Signature DateDevelopment (HUD)
is authorized to
collect this information by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d),
and by the Fair Housing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires
applicants and participants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your
income and other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your
family will pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and
monitoring HUD-assisted housing programs, to protect the Government’s financial interest, and to verify the accuracy of the information
you provide. This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or
regulatory investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as
permitted or required by law. Penalty: You must provide all of the information requested by the HA, including all Social Security Numbers
you, and all other household members age six years and older, have and use. Giving the Social Security Numbers of all household members
is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provide any of the requested information
may result in a delay or rejection of your eligibility approval.
Penalties for misusing this consent: HUD, KCHA and any owner (or any employee of HUD, KCHA 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 form is restricted to the purposes cited on the form. Any person, who knowingly or willfully 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, KCHA or the owner responsible for the unauthorized disclosure or
improper use.

3-01-2015 PAGE 2 OF 2 FORM # 486

857
SECTION 8 OFFICE
700 ANDOVER PARK W, SUITE A, TUKWILA, WA, 98188-3322
PHONE: (206) 214-1300 FAX: (206) 243-5927

STATEMENT OF FAMILY RESPONSIBILITIES

When the family's unit is approved and the HAP contract executed, the family must follow the
rules listed below in order to continue participating in the Section 8 Rental Housing Voucher
program.

A. The family MUST:

1. Supply any information that the Housing Authority (HA) or HUD determines to be
necessary including evidence of citizenship or eligible immigration status, and
information for use in a regularly scheduled reexamination or interim
reexamination of family income and composition.
2. Disclose and verify social security numbers and sign and submit consent forms for
obtaining information.
3. Supply any information requested by the HA to verify that the family is living in the
unit or information related to family absence.
4. Promptly notify the HA in writing when the family is away from the unit for an
extended period of time in accordance with HA policies.
5. Allow the HA to inspect the unit at reasonable times and after reasonable notice.
6. Notify both the HA and the Owner in writing before moving out of the unit or
terminating the lease.
7. Use the assisted unit for the residence by the family. The unit must be the family's
only residence.
8. Promptly notify the HA in writing of the birth, adoption, or court-awarded custody
of a child.

REV 0
 OFFICE USE ONLY
FORM #:
9. Request HA approval in writing to add any family HOUSEHOLD ID:
member as an occupant of the unit. Any person TICKLER #:
staying at the premises more than fourteen (14) EFFECTIVE DATE:
days in a two (2) month period shall not be
considered a guest and MUST be reported to the Housing Authority by the
tenant.
10. Promptly notify the HA in writing if any family member no longer lives in the unit.
11. Give the HA a copy of any owner issued eviction notice.
12. Pay utility bills and supply appliances that the owner is not required to supply
under the lease.
B. Any information the family supplies must be true and complete.
C. The family (including each family member) must NOT:
1. Engage in or threaten abusive or violent behavior toward Housing Authority
2. Own or have any interest in the unit (other than in a cooperative, or owner of a
manufactured home leasing a manufactured home space.
3. Commit any serious or repeated violation of the lease. (This means if you are

REV 11-22-2016 PAGE 1 OF 2 FORM # 857

 EVICTED from the unit, you will be denied further assistance).
4. Commit fraud, bribery or any other corrupt or criminal act in connection with the
program.
5. Participate in illegal drug or criminal activity.
a. Drug related criminal activity means one of the following:
1. The illegal manufacture, sale, or distribution, or possession with intent to
manufacture, sell or distribute, a controlled substance (as defined in
section 102 of the Controlled Substances Act (21 B.SC.. 802)); or
2. The illegal use, possession for personal use, of a controlled substance as
defined above.
b. Violent criminal activity means any illegal criminal activity that has as one of its
elements the use, attempted use, or threatened use of physical force against
the person or property of another.
Signature of Tenant/Head of Print Name Date
Household

Signature of Spouse/Co-Tenant Print Name Date

REV 11-22-2016 PAGE 2 OF 2 FORM # 857

c. In making its determination as to whether drug-related criminal activity or
violent criminal activity occurred, the issue will be whether the preponderance
of evidence indicates that a family has engaged in such activity, regardless of
whether the family member has been arrested or convicted.
6. Sublease or let the unit or assign the lease or transfer the unit.
7. Receive Section 8 tenant-based or Project-based program housing assistance while
receiving another housing subsidy, for the same unit or a different unit under any
other Federal, State or local housing assistance program.
8. Damage the unit or premises (other than damages from ordinary wear and tear) or
permit any guest(s) to damage the unit or premises.
9. Abuse alcohol in a way that interferes with the health, safety, or right to peaceful
enjoyment of the premises by other residents.

I understand that any changes in family income or family composition must be reported to the
Housing Authority in writing within thirty (30) days of the date of change.

I understand that I must report any household member who is a registered Sex Offender
immediately. I understand that I must notify the Housing Authority of any illegal criminal
 OFFICE USE ONLY
FORM #:
activity involving myself or any household member HOUSEHOLD ID:
immediately. TICKLER #:
EFFECTIVE DATE:
I understand that any violation of the above obligations could
result in the termination of my Section 8 assistance or denial of another voucher.

H92006
SECTION 8 OFFICE
700 ANDOVER PARK W, SUITE A, TUKWILA, WA, 98188-3322
PHONE: (206) 214-1300 FAX: (206) 243-5927
OMB Control # 2502-0581 Exp. (2/28/2019)

Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants

SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING
This form is to be provided to each applicant for federally assisted housing

Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone
number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the
purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any
special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this
contact information, but if you choose to do so, please include the relevant information on this form.
Applicant Name: Mailing
Address:

Telephone No: Cell Phone No:

Name of Additional Contact Person or Organization:

Address:

Telephone No: Cell Phone No:

E-Mail Address (if applicable):
Relationship to Applicant:
Reason for Contact: (Check all that apply)
Emergency Eviction from unit Change in lease terms
Unable to contact you Termination of rental assistance Change in house rules
Late payment of rent Assist with Recertification Process Other:
Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your
tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any
services or special care to you.
Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or
applicable law.
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 person or organization. By accepting
the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105,
including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national
origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of 1975.

REV 0
 Chec
k this box if you choose not to provide the contact information.
Signature of Applicant Date
The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork
Reduction Act of 1995 (44 U.S.C. 3501-3520). The public reporting burden is estimated at 15 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Section
644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers participating in
HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the
application for occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person associated with a social,
health, advocacy, or similar organization. The objective of providing such information is to facilitate contact by the housing provider with the person or
organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with resolving any tenancy issues
arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential
information. Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and
program and management controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not
conduct or sponsor, and a person is not required to
respond to, a collection of information, unless the 2)),&(86(21/<
collection displays a currently valid OMB control )250
number.
+286(+2/','
Privacy Statement: Public Law 102-550, authorizes
the Department of Housing and Urban 7,&./(5
Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be
used by HUD to protect disbursement data from fraudulent actions. ())(&7,9('$7(

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;WϳϰϳͲ<ͲϵϰͲϬϬϭͿ ǁŚŝĐŚƉŽŝŶƚƐŽƵƚƚŚĞĚĂŶŐĞƌƐŽĨůĞĂĚďĂƐĞĚWĂŝŶƚĂŶĚŚŽǁŝƚ
ĐĂŶďĞĂǀŽŝĚĞĚ͘;dŚĞ,ŽƵƐŝŶŐƵƚŚŽƌŝƚLJƉƌŽǀŝĚĞƐƚŚŝƐĨŽƌŵƚŽ
LJŽƵĂƚLJŽƵƌ/ŶŝƚŝĂů,ŽƵƐŝŶŐͿ

/ƵŶĚĞƌƐƚĂŶĚƚŚĂƚŝĨ/ŵŽǀĞĨƌŽŵŵLJƵŶŝƚǁŝƚŚŝŶϭϮŵŽŶƚŚƐĨƌŽŵƚŚĞĚĂƚĞ/ŵŽǀĞĚŝŶ͕/ǁŝůůŶŽƚďĞ
ŝƐƐƵĞĚĂŶĞǁǀŽƵĐŚĞƌ͘/Ĩ/ĐŚŽŽƐĞƚŽŵŽǀĞĂĨƚĞƌϭϮŵŽŶƚŚƐ/ǁŝůůďĞŝƐƐƵĞĚĂŶĞǁǀŽƵĐŚĞƌƉƌŽǀŝĚĞĚ/
ŚĂǀĞŶŽƚǀŝŽůĂƚĞĚĂŶLJŽĨŵLJĨĂŵŝůLJŽďůŝŐĂƚŝŽŶƐƵŶĚĞƌƚŚĞƉƌŽŐƌĂŵ
 OFFICE USE ONLY
FORM #:
/ǁŝůůĐŽŶƚĂĐƚŵLJ,ŽƵƐŝŶŐƵƚŚŽƌŝƚLJZĞƉƌĞƐĞŶƚĂƚŝǀĞŝĨ/ HOUSEHOLD ID:
ŚĂǀĞĂŶLJƋƵĞƐƚŝŽŶƐŽŶĂŶLJŽĨƚŚĞĂďŽǀĞŝƚĞŵƐ͕ TICKLER #:
ŽƌŝĨ/ǁŽƵůĚůŝŬĞĂŶŽƚŚĞƌĐŽƉLJŽĨƚŚĞ>ĞĂĚĂƐĞWĂŝŶƚƌŽĐŚƵƌĞ͘ EFFECTIVE DATE:

^ŝŐŶĂƚƵƌĞ͗ ĂƚĞ͗ hŶŝƚη͗

OFFICE USE ONLY

FORM #: H52675
HOUSEHOLD ID:
5(93$*(2) TICKLER #: )250
SECTION 8 OFFICE
700 ANDOVER PARK W, SUITE A, TUKWILA, WA, 98188-3322 PHONE: (206) 214-1300 EFFECTIVE DATE: FAX: (206)
243-5927

perwork Reduction Notice: Public reporting burden for this collection of information is estimated to average 7 minutes per response.
s includes the time for respondents to read the document and certify, and any recordkeeping burden. This information will be used in
processing of a tenancy. Response to this request for information is required to receive benefits. The agency may not collect this
ormation, and you are not required to complete this form, unless it displays a currently valid OMB control number. The OMB Number is
77 䇲 0266, and expires 10/31/2019.
TICE TO APPLICANTS AND PARTICIPANTS OF THE FOLLOWING HUD RENTAL ASSISTANCE PROGRAMS: z
Public Housing (24 CFR 960)
z Section 8 Housing Choice Voucher, including the Disaster Housing Assistance Program (24 CFR 982) z
Section 8 Moderate Rehabilitation (24 CFR 882) z Project-Based Voucher (24 CFR 983)

e U.S. Department of Housing and Urban Development maintains a national repository of debts owed to Public Housing Agencies (PHAs)
Section 8 landlords and adverse information of former participants who have voluntarily or involuntarily terminated
ticipation in one of the above-listed HUD rental assistance programs. This information is maintained within HUD’s Enterprise Income
ification (EIV) system, which is used by Public Housing Agencies (PHAs) and their management agents to verify employment and
REV 0
ome information of program participants, as well as, to reduce administrative and rental assistance payment errors. The EIV system is
igned to assist PHAs and HUD in ensuring that families are eligible to participate in HUD rental assistance programs and determining
correct amount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUD regulations
24 CFR 5.233.

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

hat information about you and your tenancy does HUD collect from the PHA?
e following information is collected about each member of your household (family composition): full name, date of birth,
d Social Security Number.

e following adverse information is collected once your participation in the housing program has ended, whether you voluntarily
nvoluntarily 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.
-24-2021 PAGE 1 OF 2
OMB No. 2577-0266 Expires 04/30/2023
 OFFICE USE ONLY
FORM #:
HOUSEHOLD ID:
TICKLER #:
EFFECTIVE DATE:

ho will have access to the information collected?

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

w will this information be used?

As will have access to this information during the time of application for rental assistance and reexamination of family income and
mposition for existing participants. PHAs will be able to access this information to determine a family’s suitability for initial or continued
tal assistance, and avoid providing limited Federal housing assistance to families who have previously been unable to comply with HUD
gram requirements. If the reported information is accurate, a PHA may terminate your current rental assistance and deny your future
uest for HUD rental assistance, subject to PHA policy.

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

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

hat are my rights?

accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to its implementation
he 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.

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

ou disagree with the reported information, you should contact in writing the PHA who has reported this information about you. The
A’s name ,address, and telephone numbers are listed on the Debts Owed and Termination Report. You have a right to request and
ain a copy of this report from the PHA. Inform the PHA why you dispute the information and provide any documentation that supports
ur 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
rs from the date your participation in the program ends. To ensure the availability of your records, disputes of the original debt or
mination information must be made within three years from the end of participation date; otherwise the debt and termination
ormation will be presumed correct. Only the PHA who reported the adverse information about you can delete or correct your record.
ur filing of bankruptcy will not result in the removal of debt owed or termination information from HUD’s EIV system.
wever, if you have included this debt in your bankruptcy filing and/or this debt has been discharged by the bankruptcy court, your
ord will be updated to include the bankruptcy indicator, when you provide the PHA with documentation of your bankruptcy status. The
A will notify you in writing of its action regarding your dispute within 30 days of receiving your written dispute. If the PHA determines
t the disputed information is incorrect, the PHA will update or delete the record. If the PHA determines that the disputed information is
rect, the PHA will provide an explanation as to why the information is correct.

S NOTICE WAS PROVIDED BY THE BELOW LISTED PHA: I HEREBY ACKNOWLEDGE THAT THE PHA PROVIDED ME WITH THE
DEBTS OWED TO PHAs & TERMINATION NOTICE:
NG COUNTY HOUSING AUTHORITY
OFFICE USE ONLY
Signature FORM #: Date H52675
HOUSEHOLD ID:
-24-2021 PAGE 2 OF 2 TICKLER #:
SECTION 8 OFFICE
REV 0 EFFECTIVE DATE:
 700 ANDOVER PARK W, SUITE A, TUKWILA, WA, 98188-3322

perwork Reduction Notice: Public reporting burden for this collection of information is estimated to average 7 minutes per response.
s includes the time for respondents to read the document and certify, and any recordkeeping burden. This information will be used in
processing of a tenancy. Response to this request for information is required to receive benefits. The agency may not collect this
ormation, and you are not required to complete this form, unless it displays a currently valid OMB control number. The OMB Number is
77‐0266, and expires 10/31/2019.
TICE 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)
e U.S. Department of Housing and Urban Development maintains a national repository of debts owed to Public Housing Agencies (PHAs)
Section 8 landlords and adverse information of former participants who have voluntarily or involuntarily terminated
ticipation in one of the above-listed HUD rental assistance programs. This information is maintained within HUD’s Enterprise Income
ification (EIV) system, which is used by Public Housing Agencies (PHAs) and their management agents to verify employment and
ome information of program participants, as well as, to reduce administrative and rental assistance payment errors. The EIV system is
igned to assist PHAs and HUD in ensuring that families are eligible to participate in HUD rental assistance programs and determining
correct amount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUD regulations
24 CFR 5.233.

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

hat information about you and your tenancy does HUD collect from the PHA?
e following information is collected about each member of your household (family composition): full name, date of birth,
d Social Security Number.

e following adverse information is collected once your participation in the housing program has ended, whether you voluntarily
nvoluntarily 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.
-24-2021 PAGE 1 OF 2
 OFFICE USE ONLY
FORM #:
OMB No. 2577-0266 Expires 04/30/2023 HOUSEHOLD ID:

TICKLER #:
EFFECTIVE DATE:

ho will have access to the information collected?

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

w will this information be used?

As will have access to this information during the time of application for rental assistance and reexamination of family income and
mposition for existing participants. PHAs will be able to access this information to determine a family’s suitability for initial or continued
tal assistance, and avoid providing limited Federal housing assistance to families who have previously been unable to comply with HUD
gram requirements. If the reported information is accurate, a PHA may terminate your current rental assistance and deny your future
uest for HUD rental assistance, subject to PHA policy.

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

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

hat are my rights?

accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to its implementation
he 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.

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

ou disagree with the reported information, you should contact in writing the PHA who has reported this information about you. The
A’s name ,address, and telephone numbers are listed on the Debts Owed and Termination Report. You have a right to request and
ain a copy of this report from the PHA. Inform the PHA why you dispute the information and provide any documentation that supports
ur 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
rs from the date your participation in the program ends. To ensure the availability of your records, disputes of the original debt or
mination information must be made within three years from the end of participation date; otherwise the debt and termination
ormation will be presumed correct. Only the PHA who reported the adverse information about you can delete or correct your record.
ur filing of bankruptcy will not result in the removal of debt owed or termination information from HUD’s EIV system.
wever, if you have included this debt in your bankruptcy filing and/or this debt has been discharged by the bankruptcy court, your
ord will be updated to include the bankruptcy indicator, when you provide the PHA with documentation of your bankruptcy status. The
A will notify you in writing of its action regarding your dispute within 30 days of receiving your written dispute. If the PHA determines
t the disputed information is incorrect, the PHA will update or delete the record. If the PHA determines that the disputed information is
rect, the PHA will provide an explanation as to why the information is correct.

S NOTICE WAS PROVIDED BY THE BELOW LISTED PHA: I HEREBY ACKNOWLEDGE THAT THE PHA PROVIDED ME WITH THE
DEBTS OWED TO PHAs & TERMINATION NOTICE:

Signature Date

-24-2021 PAGE 2 OF 2

REV 0
 OFFICE USE ONLY
FORM #: 432
HOUSEHOLD ID:

SECTION 8 OFFICE TICKLER #:

700 ANDOVER PARK W, SUITE A, TUKWILA, WA, 98188-3322
EFFECTIVE DATE:
PHONE: (206) 214-1300 FAX: (206) 243-5927

Spouse/ Co-Tenant/Adult Signature Date

Spouse/ Co-Tenant/Adult Signature Date

Spouse/ Co-Tenant/Adult Signature Date

7-02-2019 PAGE 1 OF 2 FORM # 432

Declaration of Eligibility Status
 OFFICE USE ONLY
FORM #:
I declare under penalty of perjury under the laws of the state of Washington that the HOUSEHOLD ID:
above is true and correct to the best of my knowledge.
TICKLER #:
EFFECTIVE DATE:

Head of Household/Adult Signature Date

What Verification Is Needed

On June 19, 1995, in accordance with Section 214 of the Housing and Community Development Act of 1980, as
amended, the King County Housing Authority implemented a change in the federal regulations which limits eligibility
for assistance based on citizenship and immigration status. Participants must complete the following information in
order to be considered for housing assistance.

FOR U.S. CITIZENS THE EVIDENCE CONSISTS OF:

A. A signed declaration of U.S. Citizenship

FOR NON-CITIZENS WHO ARE 62 YEARS OF AGE OR OLDER AND ARE RECEIVING ASSISTANCE AS OF JUNE 19.1995,
THE EVIDENCE CONSISTS OF:
A. A signed declaration of eligible immigration status; and
B. Proof of age document.

FOR ALL OTHER NON-CITIZENS, THE EVIDENCE CONSISTS OF:

A. A signed declaration of eligible immigration status;
B. A signed verification consent form;
C. One of the following USCIS documents;
i. Form I-551 Alien Registration Card
ii. Form I-94 Arrival Departure Record annotated with one of the following:
{ Admitted as Refugee Pursuant to Section 207
{ Section 208 or Asylum
{ Section 243(h) or Deportation stayed by attorney General
{ Paroled Pursuant to Section 221(d) (5) of the USCIS iii. Form I-94 Arrival
Departure Record not annotated, must be accompanied by one of the following:
{ A final court decision granting asylum
{ A letter from the USCIS asylum officer, or from the USCIS district director granting
asylum
{ A court decision granting withholding or deportation
{ A letter from an USCIS asylum officer granting withholding of deportation iv.
Form I-688 Temporary Resident Card annotated with Section 245A or Section 210
REV 0
 Form I-688B Employment authorization Card annotated with Provision of Law 274a.12(11) or
v.
Provision of Law 274a.12 vi. A receipt from the USCIS indicating the
application for issuance of a replacement

If you are not an eligible U.S. Citizen, proof of your eligibility status must be provided. A copy of your USCIS card
(front and back) or other forms of eligibility will serve as proper documentation. If you choose not to declare a
family members eligibility, that person may be included in your family and live in your unit, however, no assistance
will be received on their behalf. Please have copies of all documents prior to returning your packet.

7-02-2019 PAGE 2 OF 2 FORM # 432 OFFICE USE ONLY

SECTION 8 OFFICE FORM #: 434
700 ANDOVER PARK W, SUITE A,
TUKWILA, WA, 98188-3322
HOUSEHOLD ID:
PHONE: (206) 214-1300 FAX:
(206) 243-5927
TICKLER #:
EFFECTIVE DATE:
EXPLANATION/NOTIFICATION OF THE
NONCITIZEN RULE
On June 19, 1995, in accordance with Section 214 of the Housing and Community Development Act of 1980, as amended, the King
County Housing Authority implemented a change in the federal regulations which limits eligibility for assistance based on citizenship and
immigration status. The following is further explanation of the requirements: WHO QUALIFIES FOR ASSISTANCE:

1. U.S. Citizens; or
2. Noncitizens who have eligible immigration status in one of the following categories
a. A noncitizen lawfully admitted for permanent residence, as defined by Section 101 (a) (20) o the Immigration and Nationality
Act (INA), as an immigrant, as defined by section 101 (a) (15) of the INA (8 U.S.C. 1101 (a) (20) and 1101 (a) (15), respectively)
(immigrants). (This category includes a noncitizen admitted under section 210 or 210A of the INA (8 U.S.C. 1160 or 1161),
(special agricultural worker), who has been granted lawful temporary resident status);
b. A noncitizen who entered the United States before January 1, 1972, or such later date as enacted by law, and has continuously
maintained residence in the United States since then, and who is not eligible for citizenship, but who is deemed to be lawfully
admitted for permanent residence as a result of an exercise of discretion by the Attorney General under Section 249 of the
INA (8 U.S.C. 1259);
c. A noncitizen who is lawfully present in the United States pursuant to an admission under section 207 of the INA (8 U.S.C. 1157)
(refugee status); pursuant to the granting of asylum (which has not been terminated) under section 208 of the INA (8 U.S.C.
1158) (asylum status); or as a result of being granted conditional entry under Section 203 (a) (7) of the INA (8 U.S.C. 1153 (a)
(7) before April 1, 1980, because of persecution or fear of persecution on account of race, religion, or political opinion or
because of being uprooted by catastrophic national calamity;
d. A noncitizen who is lawfully present in the United States as a result of an exercise of discretion by the Attorney General for
emergent reasons or reasons deemed strictly in the public interest under section 212 (d) (5) of the INA (8 U.S.C. 1182 (d) (5)
 OFFICE USE ONLY
FORM #:
(parole status) HOUSEHOLD ID:
e. A noncitizen who is lawfully present in the United States as a result of the
TICKLER #:
Attorney General's withholding deportation under section 243 (h) of the
INA (8 U.S.C. 1253 (h) (threat to life or freedom); or EFFECTIVE DATE:
f. A noncitizen lawfully admitted for temporary or permanent residence under
section 245A of the INA (8 U.S.C. 1255a) (amnesty granted under INA 245A) WHAT EVIDENCE IS NEEDED:
1. For U.S. Citizens, evidence consists of a signed declaration of U.S. Citizenship.
2. For Noncitizens who are 62 years of age or older and are receiving assistance as of June 19, 1995, the evidence consists of:
3. For All other Noncitizens, the evidence consists of
a. A signed declaration of eligible immigration status;
b. A signed verification consent form:
c. One of the following USCIS documents:
i. Form I-551 Alien Registration Card
ii. Form I-94 Arrival Departure Record annotated with one of the following:
z Admitted as Refugee Pursuant to Section 207 Section
208 or Asylum z Section 243 (h) or Deportation stayed by
Attorney General z Paroled Pursuant to Section 212 (d) (5)
of the INA
iii. Form I-94 Arrival Departure Record not annotated, must be accompanied by one of the following: A final court decision
granting asylum z A letter from the USCIS asylum officer, or from the USCIS district director granting asylum.
z A court decision granting withholding or deportation
z A letter from an USCIS asylum officer granting withholding of deportation
iv. Form I-688 Temporary Resident Card annotated with Section 245A or Section 210
v. Form I-688B Employment Authorization Card annotated with Provision of Law 274a.12 (11) or Provision of Law 274a.12
vi. A receipt from the USCIS indicating the application for issuance of a replacement document for one of the above.

3-06-2020 PAGE 1 OF 2 FORM # 434

WHEN MUST IT BE SUBMITTED:
For Applicants, the evidence for a least one family member must be submitted at the time the family member applies. All family
members must submit evidence prior to being housed. WHAT HAPPENS AFTER IT IS SUBMITTED:

Once the evidence has been submitted, those declaring U.S. Citizenship and those tenants (housed as of June 19, 1995) 62 or older who
declare eligible immigration status, will be placed on the waiting list if they are applicants or continue in assisted housing if they are current
tenants.

For all other noncitizens who have claimed eligible immigration status, the submitted documents will be verified in cooperation with the
USCIS (U.S. Citizenship and Immigration Services). If eligible immigration status is verified, the family will be placed on the waiting list if they
are an applicant or continue in assisted housing if they are a current tenant. If eligible immigration status is not verified, the family will be
notified of their ineligibility and given the right to appeal the decision to either USCIS or the Housing Authority. If neither appeal is chosen,
the family's assistance will be prorated, terminated or denied. Should the family choose the appeals process and the decision is upheld, the
assistance will be prorated, denied, or terminated depending on the circumstances. Tenants in occupancy as of June 19, 1995 may be
eligible for and may request a temporary deferral of assistance under the "preservation of families" provision of the law.

VERIFICATION CONSENT FORM

Head of Household Date Spouse Date

Other Family Member over age 18 Date Other Family Member over age 18 Date

Other Family Member over age 18 Date Other Family over age 18 Date
REV 0
 3-06-2020 PAGE 2 OF 2 FORM # 434
Section 214 of the Housing and Community Development Act of 1980, as amended, requires the Housing Authority and HUD to ensure that
financial assistance is made available only to persons who are U.S. Citizens or Noncitizens who have been lawfully admitted to the United
States and hold what is considered to be "eligible immigration status". The law requires all applicants and tenants for assisted housing who
claim to have " eligible immigration status" to sign a consent form authorizing the Housing Authority and HUD to verify the information
supplied with the U.S. Citizenship and Immigration Services.

Purpose: In signing this consent form, you are authorizing the King County Housing Authority and HUD to verify your status as an immigrant
to the United States. This information is needed in order to determine your eligibility for the assisted housing benefits for which you have
applied.

Use of the Information to be Obtained: The evidence you supply to document your eligibility for housing assistance may be released by the
Housing Authority, without responsibility for the further use or transmission of the evidence by the entity receiving it, to (1) HUD, as required
by HUD, and (2) the USCIS for purposes of verification of the immigration status of the individual. The information supplied will be released
by the Housing Authority or HUD to the USCIS for the purpose of establishing eligibility for financial assistance and not for any other purpose.
However, neither the Housing Authority, nor HUD are responsible for the further use or transmission of the evidence or other information by
the USCIS.

Who must sign the form: Each Non-citizen who claims "eligible immigration status" must sign a verification consent form. Adults, age 18 or
older, must sign the form themselves. In the case of children (under age 18), the form must be signed by the adult family member who is
responsible for the minor child.

Failure to sign the form: Your failure to sign the consent form may result in the denial of eligibility or termination of assisted housing benefits,
or both. Denial of eligibility or termination of benefits is subject to the Housing Authority's grievance procedures or Section 8 informal
hearing process, whichever is applicable.

Consent: I consent to allow the King County Housing Authority, or HUD to request and obtain verification from the USCIS of the information I
have supplied regarding my immigration status. I understand that this information is necessary to determine my eligibility for housing
assistance and certify the information I have supplied is true and accurate to the best of my knowledge.

OFFICE USE ONLY

FORM #: 405
HOUSEHOLD ID:
TICKLER #:
EFFECTIVE DATE:

SECTION 8 OFFICE
 OFFICE USE ONLY
FORM #:
700 ANDOVER PARK W, SUITE A, TUKWILA, WA, 98188-3322 PHONE: (206) 214-1300
FAX: (206) 243-5927
HOUSEHOLD ID:
TICKLER #:
EFFECTIVE DATE:

DEAR EMPLOYER:
The below named individual is either an applicant for admission to, or continued occupancy in, one of
our housing assistance programs. In order to obtain complete and accurate data regarding income,
please supply the following information and return this form to us as promptly as possible. Thank you.

Housing Authority Representative

I hereby authorize my Employer named above, to release any and all information pertaining to the above
questions.

Employee /
Applicant Name of
Employee: (or Former Date of Hire:
Employee) Social If Terminated, give Termination Date:
Security #:
Job Title:
BASIS OF PAY GROSS RATE OF PAY
GROSS Salary or Wages $ Per Hour $
Commission $ Per Week $
Amt of Tips per week, if any $ Per Month $
Other $
Estimated hours of Annual Overtime: @ $ per: (Rate of Overtime Pay)
Date employee started receiving Current Rate of Pay:
Normal Hours Worked per week: , or Estimated Average Weekly Hours per year:
Total Hours Worked in the last Twelve Months: Previous Twelve-Month Employment Income: $
Is Current Employment: Temporary Permanent Seasonal Part-Time
Likelihood of Continued Employment: Yes No

Hospital or Medical Insurance Deducted from Wages: $ Per Month.

** This Form Completed By: (Employer Information)**

Company Name: Print Name & Title:
Address:Phone
Number:

REV 0
City, State, ZipFax Number:
Signature:Email:
Date:

3-01-2015 PAGE 1 OF 1 FORM # 405

 APPLYING FOR
HUD HOUSING
ASSISTANCE?
THINK ABOUT THIS…
IS FRAUD
WORTH IT?

Do You Realize…

If you commit fraud to obtain assisted housing from HUD, you could be:

x Evicted from your apartment or house. x Required to repay all

overpaid rental assistance you received. x Fined up to $10,000. x
Imprisoned for up to five years. x Prohibited from receiving future
assistance.
x Subject to State and local government penalties.

Do You Know…

You are committing fraud if you sign a form knowing that you provided false or misleading
information.

The information you provide on housing assistance application and recertification forms will be
checked. The local housing agency, HUD, or the Office of Inspector General will check the
income and asset information you provide with other Federal, State, or local governments and
with private agencies. Certifying false information is fraud.

So Be Careful!

When you fill out your application and yearly recertification for assisted housing from
HUD make sure your answers to the questions are accurate and honest. You must include:

All sources of income and changes in income you or any members of your household receive,
such as wages, welfare payments, social security and veterans’ benefits, pensions,
retirement, etc.

Any money you receive on behalf of your children, such as child support, AFDC payments,
social security for children, etc.
 form HUD-1141
(12/2005)
Any increase in income, such as wages from a new job or an expected pay raise or bonus.

All assets, such as bank accounts, savings bonds, certificates of deposit, stocks, real estate,
etc., that are owned by you or any member of your household.

All income from assets, such as interest from savings and checking accounts, stock dividends,
etc.

Any business or asset (your home) that you sold in the last two years at less than full value.

The names of everyone, adults or children, relatives and non-relatives, who are living with
you and make up your household.

(Important Notice for Hurricane Katrina and Hurricane Rita Evacuees: HUD’s reporting
requirements may be temporarily waived or suspended because of your circumstances.
Contact the local housing agency before you complete the housing assistance application.)

Ask Questions

If you don’t understand something on the application or recertification forms, always ask
questions. It’s better to be safe than sorry.

Watch Out for Housing Assistance Scams!

x Don’t pay money to have someone fill out housing assistance application and
recertification forms for you.
x Don’t pay money to move up on a waiting list. x Don’t pay
for anything that is not covered by your lease. x Get a receipt
for any money you pay.
x Get a written explanation if you are required to pay for anything other than rent
(maintenance or utility charges).

Report Fraud

If you know of anyone who provided false information on a HUD housing assistance application
or recertification or if anyone tells you to provide false information, report that person to the
HUD Office of Inspector General Hotline. You can call the Hotline toll-free Monday through
Friday, from 10:00 a.m. to 4:30 p.m., Eastern Time, at 1-800-347-3735. You can fax information
to (202) 708-4829 or e-mail it to [email protected]. You can write the Hotline at:
 HUD OIG Hotline, GFI
th
451 7 Street, SW
Washington, DC 20410

December 2005
OFFICE USE ONLY
FORM #: 805
HOUSEHOLD ID:
TICKLER #:
SECTION 8 OFFICE
700 ANDOVER PARK W, SUITE A, TUKWILA, WA, 98188-3322 EFFECTIVE DATE:
PHONE: (206) 214-1300 FAX: (206) 243-5927

VOLUNTARY PORTABILITY
I, , request that King County Housing
Authority transfer my Section 8 Voucher to:

New Housing Authority Name:

Address:
City, State, and ZIP Code:

Portability Contact Person:

Phone Number:
Fax Number:
Email Address:

I understand that my initial Public Housing Authority (PHA), King County

Housing Authority, will limit my ability to move from the new PHA's
jurisdiction for the next 12-month period.
I understand that by signing this statement I will adhere to its contents.

Signature:

Date:

Your Phone:

Your Email Address:

REV 09-29-2022 PAGE 1 OF 2 FORM # 805

SECTION 8 PORTABILITY

WHATISPORTABILITY?
Portability lets you keep your Section 8 voucher if you move to a unit in a different Housing
Authority’s jurisdiction.

WHYWOULDIWANTPORTABILITY?
With portability, you can keep your Section 8 voucher as you move to be closer to a new job,
education, or other opportunities.

WHOISELIGIBLEFORPORTABILITY?
You are eligible for portability if you:

x Lived in KCHA’s jurisdiction when you appliedfor a Section 8 voucher.

x Have lived in a unit in KCHA’s jurisdiction with a Section 8 voucher for atleast12months.

If you lived outsideKCHA’s jurisdiction when you applied for a Section 8 voucher with KCHA, you
must live in a unit in KCHA’s jurisdiction for 12monthsbefore you are eligible for portability.

WHERECANIMOVE?
After we determine that you are eligible for portability, you can move anywhere in the United
States with a Section 8 program.

HOWDOESTHEPORTABILITYPROCESSWORK?
1. We will determine if you are eligible to move.
 2. If you are eligible, we will identify the Housing Authority whose jurisdiction you want to
move to. 3. You will sign a Portability Release Form. This form gives KCHA permission to
send the new Housing Authority your paperwork.
4. You should contact the new Housing Authority for more information about portability. They
will probably have different procedures from KCHA

AFTERIPORT,WILLTHEREBEANYDIFFERENCES?
Your new Housing Authority may be different from KCHA:

x The new Housing Authority will have different rules from KCHA.
x The new Housing Authority will have different payment standards. This can change the
rental limits for units you can rent.
x The new Housing Authority may have different subsidy standards. This can change how
many bedrooms your household is eligible for.

REV 09-29-2022 PAGE 2 OF 2 FORM # 805

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