RECERTIFICATION PACKET

ST CHARLES PARISH HOUSING AUTHORITY

PERSONAL DECLARATION FOR ASSISTANCE PROGRAMS

(Print Legal Name as it appears on Social Security Card or other identification:)

Street Address

Mailing Address

List all other persons WHO WILL LIVE IN THE HOUSEHOLD UNDER ASSISTANCE:
Print Legal Name as it appears on Social Security Card or other Legal Identification)

Person1

Person2

Person3

Person4

Person5

Person6

Person7

Person8


List all family members 17 or older who are FULL TIME STUI)ENTs and the Name of their school.


All income for every person in this family from any source or or any type mustbe listed on this application. There are no exceptions? Does any
person in this household receive any of the following types or income. even part time or occasionally? write YES or No in the space for each
type of income listed.

List all family members who receive income, all types of income for that member and the GROSS amounts per month BEFORE any deductions.

Does any person in this housebold own full or partial interest in any of the following asset: write YES or No in the space for eacb type of assets.

For each asset stated above List, the type, tbe location or the asset or the name of the bank or holding company, account number and the current value.


If YES. complete the following per child school

If YES, complete the following:

Give the following medical expense information only if the head of household or the Spouse is age 62 or older, or is handicapped. or disabled.

List the amounts expected to be paid out or pocket by your household during the next 12 months:

what are your household's current monthly expenses? List then, based on the previous month.



List the current or former place or employment for each household member? Put “(Cr for current and “(F) for former Employer:

List all the vehicles the family owns.

All family members age 18 and over should review the information listed on this form, the privacy act statement, and any release of information forms that may be required. The declaration must be signed by the Head of Household and Adult household members.

CERTIFICATION OF APPLICANT: I do hereby swear and attest that each section or this declaration has been thoroughly explained to me and that all the information given by me on this declaration is true and correct. I understand that I must report any changes in income, assets, family composition, or address to the St Charles Parish Housing Authority within 10 days of the change and that failure to make such report can adversely impact my ability to receive assistance. I further understand that false information is grounds for termination of assistance.

WARNING: Title 18, Section 1001 or the U.S. Code, states that a person is guilty or a felony for knowingly and willing making false or fraudulent statements to any Department or Agency or the U.S. or the U.S. Department or housing and Urban Development.