VERIFICATION OF FOSTER CARE

(for use in verifying full-time student eligibility) Page 1 of 2

Date:
Project Name: / Project Address:
Telephone: / Address 2:
Fax: / TTD/TTY:

TO:

Name / RE: Tenant / Applicant Name:
Address: / Address:
City/State/Zip / City/State/Zip:
SSN:

The individual named directly above is an applicant/tenant of a housing program that provides an exemption from a prohibition against full-time students if the student was previously in foster care. The information provided will remain confidential to satisfaction of that stated purpose only. We ask your prompt cooperation in providing the following information and returning it to the property listed at the top of the page (via fax or mail) to assure timely processing of the application for housing. The applicant/resident has consented to the release of this information as shown below. PLEASE RETURN WITHIN 3 DAYS!

Signed ______, Property Representative

HOUSEHOLD MEMBER RELEASE
TO THE HOUSEHOLD MEMBER:
RELEASE: I hereby authorize the release of the requested information.
Signature ______Date______
Note to Applicant/Tenant: You do not have to sign this form if either the requesting organization or the organization supplying the information is left blank.

TO WHOM IT MAY CONCERN:

For purposes of determining the eligibility of full-time students formerly in out-of-home placement in a foster care system governed by Title IV, part B or E of the social Security Act Foster Care Eligibility Program, the above reference individual:

Has previously been in foster care from ______to ______.

Has not previously been in foster care

Signature______

Print Name______

Title ______

Organization ______

Address: ______

Phone______Fax______

Date______

PENALTIES FOR MISUSING THIS FORM
Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government, HUD, and any owner (or any employee of HUD 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 verification form is restricted to the purposes cited above. 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 or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7) and (8). Violation of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).

TM Associates Management, Inc. 0316