CERTIFICATION THAT A SOCIAL SECURITY NUMBER
HAS NEVER BEEN ASSIGNED
Property: / Unit #:Adult Applicant/Resident:
I, , certify that I have never been assigned a Social Security Number.
For a Minor (under age 18 years) in the Household:
I am the Head of Household and certify that has never been assigned a Social Security Number.
I have read the "Penalties for Misusing this Consent" and the "Warning" statements below in regard to making false or inaccurate statements to any department or agency of the United States Government, HUD, Rural Housing Service (RHS) and any Owner (or any employee of the listed agencies and/or the Owner).
Signature: / Date:Form MUST be Notarized: OR Witnessed:
Subscribed and sworn to before me this______day of ______, ______/ Printed Name of Witness:
Signature of Notary Public: / Signature of Witness:
My Commission Expires: / Date:
PENALTIES FOR MISUSING THIS CONSENT: Title 18, Section 1001 of the U.S. Code state 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, the PHA, Rural Housing Service (RHS) and any Owner (or any employee of HUD, the PHA, RHS 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 or information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the PHA, RHS 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 42 U.S.C. 208 (f) (g) and (h). Violations of these provisions are cited as violations of 42 U.S.C. 408 f, g and h.
WARNING: Section 1001 of Title 18, United State code provides: “Whoever, in any matter within any jurisdiction of any department or agency of the United States knowingly or willfully falsifies, conceals or covers up… a material fact, or makes any false, fictitious or fraudulent statements or representation, or makes any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than 5 years or both.”
NOTE:
This Apartment Community does not discriminate on the basis of handicapped status in the admission or access to, or treatment or employment in, its federally assisted programs and activities.
Certification SS# Not Assigned (6/03) Page 1 of 1 TC-6(a)