SACRAMENTO HOUSING & REDEVELOPMENT AGENCY

ANNUAL RECERTIFICATION
PHONE (916) 440-1390 FAX (916) 449-1285

Please complete all sections of this form and answer all questions by writing “YES” or “NO” (do not abbreviate) as
indicated by the arrows. Assistance is available by calling the number above.

WARNING: Omitting information or making false statements on this annual recertification may be considered
FRAUD and may result in TERMINATION from the program and/or CRIMINAL PROSECUTION.

HEAD OF HOUSEHOLD T-Code:

Last Name First Name Home Phone Number
( )

Subsidized Street Address Apt. Number Cell Phone Number

( )

City State Zip Code Email Address

SECTION I - HOUSEHOLD COMPOSITION

If you need additional space to answer the questions, you may use another sheet of paper and attach it to this form.
A. FAMILY HOUSEHOLD COMPOSITION
Please list ALL people living in your home, including live-in aides. List the Head of Household first followed by
spouse/co-head then oldest to youngest household members.
Submit a copy of a County issued Birth Certificate (not a hospital issued birth certificate), Social Security Card, and 214
Declaration form for any child born in the past 12 months.
Submit a current photo I.D. for any household member who turns 18 years of age for this recertification.
Relationship to Marital Status
Full Name Lives with me at least
Head of (For Adults or Married
As appears on Social Security Card 51% of the time
Household Minors Only)
1) SELF

2) Yes No

3) Yes No

4) Yes No

5) Yes No

6) Yes No

7) Yes No

8) Yes No

SHRA Annual Recertification Packet Page 1 of 15 Revised 04.22.2024 MO

You MUST answer each question below by writing “YES” or “NO” (do not abbreviate) in the shaded boxes as
indicated by the arrows. If you answered “YES”, please fill out information below.

B. STUDENT STATUS YES/NO

Do you or any household member(s) 18 or older attend high-school, college and or vocational school?

If yes, complete below and provide current school generated verification indicating current student status and
current financial aid budget and disbursement award letter.
PART OR FULL SCHOOL NAME AND ADDRESS FINANCIAL AID AWARD
STUDENT NAME
TIME? (Street, City, State and Zip Code) YES/NO AMOUNT

SECTION II – HOUSEHOLD INCOME

Submit the required copies of the documents for each type of income. Verifications of income and assets should be current.
Current is defined as being within 60 days of the date of this request.

If you need additional space, you may use another sheet of paper and attach it to this form.
TYPE OF INCOME REQUIRED DOCUMENTS YOU MUST SUBMIT
Wages Copy of most current 2 consecutive paycheck stubs.
Social Security (SSA) Copy of current benefit letter - you may create an on-line account at
www.ssa.gov/myaccount OR call to obtain a printout from the SSA office at 1-800-772-
Supplemental Security
1213.
Income (SSI)
If an overpayment is being deducted from your SSA/SSI monthly income, submit a
verification letter from the SSA office showing: 1) the balance of overpayment 2) the
monthly deduction amount, and 3) the date when the overpayment amount will stop
being deducted from your benefits.
Unemployment Insurance Current printout from EDD (Employment Development Department) showing the amount of
State Disability Insurance the benefit or a copy of the award letter and/or 2 current consecutive payment stubs.
CalWorks / Cash Aid Current printout showing monthly award and family members from DHA (Department of
General Assistance Human Assistance).
Child Support If child support payments are not sporadic and are processed through the Child Support
Office, provide 2 current consecutive monthly printouts showing the amount of child
support received. If payments are sporadic, then provide a printout showing the last 12 full
months of payments.

If child support is not processed through the Child Support office, submit a letter from the
child support provider with their full name, address, phone number, and the amount of
monthly payments.
Adoption Assistance Current statement stating the benefit amount and frequency and/or the last 2 current
payment stubs.
Retirement / Veterans / or Current award letter stating the pension amount and frequency and/or the last 2 current
Private Pensions and consecutive payment stubs.
Workers’ Compensation Current statement or letter stating the benefit amount and frequency and/or the last 2
payment stubs.
Cash/Gifts Letter from provider detailing the source and amount of cash/gifts received monthly. For
gifts, you must apply a monetary (cash) value. For example: If you receive groceries every
month you must declare it as a gift and indicate the dollar value of the goods.
Self-Employment Previous year’s Federal and State Income Tax returns with all schedules attached. Self-
employment may include Lyft, Uber, Doordash, Instacart, Etsy, income from social media
content creation, etc.

SHRA Annual Recertification Packet Page 2 of 15 Revised 04.22.2024 MO

You MUST answer each question below by writing “YES” or “NO” (do not abbreviate) in the shaded boxes as
indicated by the arrows. If you answered “YES” to any question, please fill out the information below the
questions for each household member(s) who receives the income(s).
A. SSI / PENSION / OTHER BENEFITS YES/NO
Do you or any household member(s) receive Social Security/SSI benefits?
Is there an overpayment being deducted from you or your household member(s)’ Social Security/SSI
benefits?

If yes, please submit a verification letter from the SSA office showing:
1) the balance of the overpayment, 2) the monthly deduction amount, and 3) the date when the overpayment
amount will stop being deducted from your benefits.
Do you or any household member(s) receive distributions or payments from a pension, retirement
account, annuity, or VA benefits?
Do you or any household member(s) receive workers’ compensation benefits or payments from EDD for
unemployment insurance or state disability insurance?

Frequency
Name of Household Member Name of Agency/Office Amount
(weekly, monthly, etc.)
$

B. EMPLOYMENT YES/NO
Do you or any household member(s) receive full/part-time/seasonal job earnings or severance pay?
Do you or any household member(s) receive cash, tips, or bonuses not reported on a paycheck stub?
Do you or any household member(s) receive military, or reserve pay?

Employer Phone & Fax Frequency

Household Employer Address Pay (hourly,
Employer Name Number
Member Name (Street, City, State & ZIP) Amount weekly,
(include area code)
monthly, etc.)
( )
( )
( )
( )
( )
( )
( )
( )

C. SELF EMPLOYMENT YES/NO

Are you or any household member(s) self-employed?
If yes, attach a copy of the most recent Federal and State Income Tax returns with all schedules
attached. Self-employment may include Lyft, Uber, Doordash, Instacart, Etsy, income from social media
content creation, etc.
Estimated
Household Business Annual Total Estimated Net Profit
Type of Business/Work Gross
Member Name Start Date Expenses (total profit – expenses)
Annual Profit

SHRA Annual Recertification Packet Page 3 of 15 Revised 04.22.2024 MO

 D. TERMINATION OF EMPLOYMENT - If you need additional space, submit a separate page. YES/NO
Have you or any household member(s) stopped working at any job in the last 12 months, even if already
reported?
If yes, attach a termination notice and/or letter of separation.
Former Phone & Fax
Household Member Former Employer Former Employer Address Employment
Number
Name Name (include street, City, State & ZIP) Termination Date
(include area code)
( )
( )
( )
( )

E. PUBLIC ASSISTANCE BENEFITS YES/NO

Do you or any household member(s) receive public assistance such as: cash aid, food stamps (CalFresh),
tribal TANF, adoption assistance, KinGap, foster care payments, CAPI, or other?
Name of Household Member Monthly Amount Type of Benefit

F. CHILD SUPPORT OR ALIMONY BENEFIT(S) YES/NO

Do you or any household member(s) receive child support payments from any source?

Do you or any household member(s) receive alimony payments from any source?
Person/Agency Paying Phone Number of
Address of Person/Agency
Name of Child or Monthly Support
Paying Support Person/ Agency
Recipient Amount (Parent, ex-spouse or County
service)
(Street, City, State & ZIP) Paying Support

( )

( )

( )

G. CONTRIBUTIONS YES/NO
Does anyone outside your household give you money or pay any of your bills?
Does anyone outside your household buy you supplies such as groceries, etc.?
Contribution Phone
Household Member Name of Address of Contributor
Amount/ How Often Number of
Receiving Contribution Contributor (include street, City, State & ZIP)
Estimated Value Contributor

( )

( )

( )

( )

SHRA Annual Recertification Packet Page 4 of 15 Revised 04.22.2024 MO

 H. OTHER INCOME YES/NO
Do you or any household member(s) have any other sources of income not listed above?

Name of Household Member Monthly Amount Source of Income

I. ZERO INCOME YES/NO

Is there an adult household member (18 years or older) who has no ($0) income?
(The household member should NOT sign this section if they receive income such as contributions or gifts, financial
aid, workers’ compensation, unemployment insurance, temporary disability payments, spousal support, income from
insurance payouts, or other money received for the household.)
PRINT NAME of household member SIGNATURE of household member
claiming No-Income status claiming No-Income status

SECTION III – ACCOUNTS / ASSETS

Please submit a copy of the most recent statement (dated within the last 60 days) for all accounts / assets
for each household member. If you need additional space to answer the questions, you may use another sheet
of paper and attach it to this form.

TYPE OF ASSET REQUIRED DOCUMENTS

Checking and/or Provide the most current statement(s).
Savings Accounts Printouts of transaction histories will not be accepted.

Retirement Accounts Provide the most current (monthly/quarterly) statement for these accounts.
(IRA, 401K 457, etc.) The statement should include the current cash value/vested balance and annual rate of
return (if applicable for the plan/investment type). Documentation should show if payments
are being made from any of these accounts for any reasons.

Life Insurance Provide current verification of the CASH SURRENDER VALUE of life insurance
policy/policies.

Stocks, bonds, or Provide most current documentation indicating current number of shares, current market
treasury bills value, and information on costs or fees associated with converting the asset to cash.
For bonds or treasury bills, provide a copy of the bond or bill if available.

Money Market Provide most current documentation of these funds indicating if any payments are being
Fund/Trust Fund made to any member of the household, as well as any costs associated with converting
the funds to cash.

Real Estate (including Provide a copy of the title, and the most current mortgage statement.
any real estate sold over
the last 2 years)

Business/Business Provide a copy of most recent tax return with all applicable schedules.
Equipment

SHRA Annual Recertification Packet Page 5 of 15 Revised 04.22.2024 MO

You MUST answer each question below by writing “YES” or “NO” (do not abbreviate) in the shaded boxes as
indicated by the arrows. If you answered “YES” to any question, please fill out the information below for each
household member(s) with the asset(s). If you have more than one asset, please list each one separately.

A. ACCOUNTS / ASSETS YES/NO

Do you or any household member(s) have a savings or checking account?
Do you or any household member(s) have a retirement plan (401K, IRA, 457, etc.)
Do you or any household member(s) have life insurance? (List only the cash surrender value below.)
Do you or any household member(s) have stocks, bonds, treasury bills or certificate of deposit (CD)?
Do you or any household member(s) have a money market fund/trust fund?
ACCOUNTS / ASSETS (continued)
Current Anticipated Earned
Name of Household Company/Bank Type of Account Number/
Balance – or Income
Member Name Account/Policy Policy Number
Cash Value If none, enter 0

B. ACCOUNTS / ASSETS (continued) YES/NO

Do you or anyone in your household own (individually or in partnership) commercial real estate?
If yes, name of household member/owner: Commercial Property Address:

(Provide a copy of the title, most current mortgage statement)

Do you, or anyone in your household own (individually or in partnership), have a legal right to reside in,
or have legal authority to sell residential real estate or a manufactured home?

If yes, name of household member/owner: Residential Property Address:

(Provide a copy of the title, most current mortgage statement)

[Optional]
If you, or a household member own residential real estate or a manufactured home, do you live in this
residential property/home?

If no, why don’t you live in the residential property/home owned by you or a household member?
Use an additional sheet if necessary.

Have you or anyone in your household sold any real estate in the last two years?
Do you own a business or have business equipment?
Do you have other assets not listed above? If yes, please write in the information below.
Current Anticipated Earned
Name of Household Company/Bank Type of
Account Number Balance – or Income
member Name Account / Asset
Cash Value If none, enter 0

SHRA Annual Recertification Packet Page 6 of 15 Revised 04.22.2024 MO

 C. CLOSED ACCOUNTS / ASSETS YES/NO
Have you or any household member(s) closed any bank account or other asset within the last 12 months?
If YES, please fill out information below for the household member(s) with that asset(s) and submit verification
from the bank or financial institution that the account(s) was/were closed.
Name of Household Company/Bank Name Type of Account Account Date Closed
member Number

SECTION IV - EXPENSES
Submit the required copies of the documents for each type of expense.
If you need additional space to answer the questions, you may use another sheet of paper and attach it to this form.

TYPE OF REQUIRED DOCUMENTS YOU MUST SUBMIT

EXPENSE
Childcare If you have childcare expenses, complete section A-Childcare Expenses below, listing each child
Expense receiving childcare, in addition to providing the following documents for:
Childcare agency–Current cost statement from the childcare agency (dated 60 days from the
date of this request).
Childcare from an individual provider-canceled checks or money order receipts for the last 3
months or your previous year’s tax return with the childcare expense exemption.

Medical Medical expenses deduction may be considered only if the head-of-household or spouse/partner is 62
Expense years of age or older - or - disabled.
If you are qualified, please provide current pharmacy history along with a statement(s) from the
prescribing medical professional indicating the prescription is medically necessary and on-going.
Provide current receipts, bills, verification of medical/dental insurance payments, deductible, and/or co-
payments.
Expenses that are less than 3% of your annual gross income will not be considered as a deduction due
to HUD policy.

You MUST answer each question below by writing “YES” or “NO” (do not abbreviate) in the shaded boxes as
indicated by the arrows. DO NOT LEAVE ANY QUESTIONS BLANK. If you answer “YES”, please fill out
information below for the household member(s) with that expense(s).

A. CHILDCARE EXPENSES – If you need additional space, submit a separate page. YES/NO
Do you pay childcare for a child(ren) 12 and under?
Is any portion of your childcare expense reimbursed from an outside agency or person?

Name of Childcare
Address of Provider Provider Phone Monthly Amount Paid for
Name of Child Provider and Tax I.D. /
(include Street, City, State & ZIP) Number Childcare
Social Security #

( )

( )

( )

( )

SHRA Annual Recertification Packet Page 7 of 15 Revised 04.22.2024 MO

 B. MEDICAL EXPENSES YES/NO
1) Is the head of household, co-head or spouse disabled?
2) Is the head of household, co-head or spouse 62 years of age or older?
3) Are there any other household member(s) who is/are disabled?
If yes, who?

If you answered “YES” to questions 1 or 2 in section B. Medical Expenses above, and any household member(s)
anticipate having on-going out-of-pocket (unreimbursed, not paid by insurance or other source) medical expense(s)
in the next 12 months that exceed 3% of your annual income, complete the information below and provide proof of
expenses to have your medical expenses evaluated as a possible deduction.

Name of Person(s) Name And Address of Out-Of-Pocket

Type of Expense Phone/Fax Number
the Expense(s) is for Source to Verify Medical Expense(s) Monthly Cost

SHRA Annual Recertification Packet Page 8 of 15 Revised 04.22.2024 MO

 SECTION V – SUPPLEMENTAL INFORMATION

You MUST answer each question below by writing “YES” or “NO” (do not abbreviate) in the shaded boxes
as indicated by the arrows. If you answer “YES”, please fill out information below for that household
member(s). DO NOT LEAVE ANY QUESTIONS BLANK.

A. HOUSEHOLD INFORMATION YES/NO

Were any household members temporarily absent from the home for 30 or more days in the past year
(e.g., School, Military, etc.)?
If yes, who? When?

Has anyone moved INTO your unit within the last 12 months?

If yes, who? When?

Has anyone moved OUT OF your unit within the last 12 months?

If yes, who? When?

Have you or any other adult member of your household ever used any other name(s)
or social security number(s) other than the one listed on page one (1)?
If yes, please give name(s) and/or Social Security number(s):

Have you or anyone in your household been arrested or convicted of any criminal activity in the
last 12 months (even if previously disclosed)?
If yes, list who was arrested or convicted and all arrests, violations, and convictions including those that were
dismissed, discharged, or overturned:

Are you or any member of your household subject to a lifetime registration requirement under a State
Sex Offender Registration Program?
If yes, list name of registrant and complete address where currently registered:

Has the responsibility for paying any of the utilities (PG&E, SMUD, water, or trash) changed between the
owner and tenant during the last 12 months?
If yes, when and explain what has changed.

Are you related by blood or marriage to the owner of your rental unit?

If yes, describe your relationship to the owner of your rental unit:

Does anyone residing OUTSIDE of your household receive mail at your residence or claim it as their
residence?
If yes, who and for what length of time?

SHRA Annual Recertification Packet Page 9 of 15 Revised 04.22.2024 MO

 SECTION VI – CERTIFICATION OF THE FAMILY

PARTICIPANT CERTIFICATION

I/we declare under penalty of perjury under the laws of the State of California that the foregoing is true,
correct, and complete. I/we certify that I/we have provided a Social Security Number for all family
members as required and that the Social Security Numbers listed below are correct and have been
assigned by the Social Security Administration. I/we understand that the Housing Authority will
research public records and conduct computer matching searches to verify the information provided
in this declaration. I/we also understand that I/we must report all changes in household members and
income to the Housing Authority when they occur.

WARNING Title 18, Section 1001 of the United States Code makes it a criminal offense to make willful false
statements or presentation to any Department or Agency of the United States as to any matter within its
jurisdiction. Providing false statements or information will result in termination of assistance and eligibility,
and may be subject to criminal prosecution.

Signature: Date:
Head of Household

Signature: Date:
Spouse/Co-head

Signature: Date:
Other family member (18 yrs & older)

Signature: Date:
Other family member (18 yrs & older)

Signature: Date:
Other family member (18 yrs & older)

SHRA Annual Recertification Packet Page 10 of 15 Revised 04.22.2024 MO

 FAMILY OBLIGATIONS
Please READ the following Family Obligations. EACH ADULT FAMILY MEMBER MUST SIGN the Most
Commonly Violated Family Obligations and Acknowledgement page.

The family’s participation in the HCV program may be terminated per Title 24 Code of the Federal Regulations
(CFR) Part 982.551 and the Housing Authority’s Administrative policy if any family member violates any family
obligation under the program for any or all of the following reasons.

Supplying Required Information

1. The family must supply any information that the Public Housing Authority (PHA) or the US Department of
Housing and Urban Development (HUD) determines is necessary in the administration of the program,
including submission of required evidence of citizenship or eligible immigration status. “Information”
includes any requested certification, release, or other documentation.
2. The family must supply any information requested by the PHA or HUD for use in a regularly scheduled
reexamination or interim reexamination of family income and composition in accordance with HUD
requirements.
3. The family must notify the PHA in writing, within 30 days, of all changes in income by any family member.
4. The family must disclose and verify social security numbers and must sign and submit consent forms for
obtaining information.
5. Any information supplied by the family must be true and correct.
Housing Quality Standards (HQS) breach caused by the family.
1. The rental unit must be kept in good condition and pass inspection.
2. The family is responsible for any tenant-caused damage or other conditions that violate HQS and must
correct the repairs within the specified timeline.
3. The family is responsible for a breach of HQS that is caused by any of the following:
a. The family fails to pay for any utilities that the owner is not required to pay for, but which are to be
paid by the tenant; or
b. The family fails to provide and maintain any appliances that the owner is not required to provide,
but which are to be provided by the tenant; or
c. Any member of the household or guest damages the dwelling unit or premises (damage beyond
ordinary wear and tear).
Allowing PHA Inspections. The family must allow the PHA to inspect the unit at reasonable times after
reasonable notice.
Violation of lease. The family must not commit any serious or repeated violations of the lease. An incident or
incidents of actual or threatened domestic violence, dating violence, or stalking will not be construed as serious or
repeated lease violations by the victim or threatened victim of the domestic violence, dating violence, or staking,
or as good cause to terminate the tenancy, occupancy rights, or assistance of the victim.
Family notice of move or lease termination. The family must notify the PHA and the owner before the family
moves out of the unit or terminates the lease on notice to the owner.
Owner eviction notice. The family must promptly give the PHA a copy of any owner eviction notice. The family
must give the PHA a copy of any owner eviction notice within 15 days. This includes 30-day notices, “3-Day
Notice to Perform or Quit” as well as other forms of warning notices.
Use and occupancy of unit.
1. The family must use the assisted unit for residence by the family. The unit must be the family’s only
residence.
2. The composition of the assisted family residing in the unit must be approved by the PHA. The family must
notify the PHA in writing, within 30 days, of the birth, adoption, or court-awarded custody of a child.
3. The family must request PHA approval in advance to add any other family member as an occupant of the
unit. No other person (i.e., only members of the assisted family) may reside in the unit, except for a foster
child or live-in aide with prior approval.

SHRA Annual Recertification Packet Page 11 of 15 Revised 04.22.2024 MO

 4. The family must promptly notify the PHA in writing, within 30 days if any family member no longer resides
in the unit.
a. The family must receive in writing the PHA’s approval BEFORE adding any other family member
as an occupant of the unit.
b. The family must notify the PHA in writing within 30 days if any family member is away from the unit
for at least 30 days.
5. If the PHA has given approval, a foster child or live-in aide may reside in the unit.
6. Members of the household may engage in legal profit-making activities in the unit, but only if such
activities are incidental to primary use of the unit for residence by members of the family.
7. The family must not sublease or sublet the unit.
8. The family must not assign the lease or transfer the unit.
Mail. The family must not have their mail forwarded to another address. Post Office Box mailing address
changes must be pre-approved by the PHA.
Absence from the unit. The family must promptly notify the PHA of absences from the unit and supply any
information or certification requested by the PHA to verify that the family is living in the unit, or related to family
absence from the unit, including PHA-requested information or certification on the purpose of the family’s
absence.
Interest in the unit. The family must not own or have any interest in the unit. The PHA will not approve a
Housing Assistance Payment (HAP) contract to any relative of the tenant who is the property owner unless the
lease was effective prior to June 17, 1998. The PHA may waive this restriction as a reasonable accommodation
for a family member who is a person with a disability. This means that tenants may not rent from family members,
including grandparents, parents, siblings, aunts, uncles, nieces, nephews, children, etc.
Fraud and other program violations. The members of the family must not commit fraud, bribery or any corrupt
or criminal act in connection with the program.
Crime by household members. The members of the household may not engage in drug-related criminal
activity, violent criminal activity or other criminal activity that threatens the health, safety, or right to peaceful
enjoyment of other residents and persons residing in the immediate vicinity of the premises. Criminal activity
directly related to domestic violence, dating violence, or stalking engaged in by a member of a tenant’s household
or any guest or other person under the tenant’s control, shall not be cause for termination of tenancy, occupancy
rights, or assistance of the victim if the tenant or immediate family member of the tenant is the victim.
1. The Head of Household is responsible for disclosing the criminal activity of ALL family members when
asked. If the head of household fails to disclose such activity, the PHA will issue a termination of
assistance.
2. Household members may not engage in the use of any illegal drug. The federal government has declared
marijuana an illegal drug and its use or possession to be illegal. Marijuana use or possession includes the
growing, cultivating, selling, bartering, exchanging or other activity that furthers the proliferation and/or use
of marijuana in or near your subsidized unit.
3. Household members may not engage in threatening, abusive or violent behavior toward PHA personnel or
contractors.
Alcohol abuse by household members. Members of the household must not abuse alcohol in a way that
threatens the health, safety or right to peaceful enjoyment of other residents and persons residing in the
immediate vicinity of the premises.
Other housing assistance. An assisted family, or members of the family, may not receive Housing Choice
Voucher assistance while receiving another housing subsidy, for the same unit or for a different unit, under
duplicative (as determined by HUD or in accordance with HUD requirements) federal, state, or local housing
assistance programs.
Debts owed. The family may not breach an agreement with a PHA to pay amounts owed to a PHA.
NOTE: People receiving mail at the assisted address are thought to be living in the unit and may be considered
unauthorized residents of the rental unit. DO NOT LET OTHER PEOPLE USE YOUR MAILING ADDRESS.
Additionally, people who are listed as the bill payer for the utilities at a rental unit are thought to be living in the
unit and may be considered unauthorized residents of the rental unit.

SHRA Annual Recertification Packet Page 12 of 15 Revised 04.22.2024 MO

 MOST COMMONLY VIOLATED
FAMILY OBLIGATIONS AND ACKNOWLEDGEMENT

The following family obligations are the most commonly violated. Failure to comply with these and all family
obligations may result in termination from the program. Do not let this happen to you!

Please make sure you understand the family obligations of the program and if you have any questions, please
contact your caseworker for clarification. By signing this acknowledgement, you and your household member(s)
are certifying that you have read and understand the Family Obligations requirement of the housing program.

The family must request PHA approval in advance to add any other family member as an occupant of
the unit. No other person (i.e., only members of the assisted family) may reside in the unit, except for
a foster child or live-in aide with prior approval.

The family must notify the PHA in writing, within 30 days of any changes in the household composition.

The Family must notify the PHA in writing, within 30 days, of all changes in income by any family
member.
People receiving mail at the assisted address are thought to be living in the unit and may be
considered unauthorized residents of the rental unit. DO NOT LET OTHER PEOPLE USE YOUR
MAILING ADDRESS. Additionally, people who are listed as the bill payer for the utilities at a rental
unit are thought to be living in the unit and may be considered unauthorized residents of the rental unit.

PARTICIPANT CERTIFICATION: I/we do hereby swear and attest that I/we read, understand and have received a
copy of the complete list of Family Obligations.

Signature: Date:
Head of Household

Signature: Date:
Spouse/Co-head

Signature: Date:
Other family member (18 yrs & older)

Signature: Date:
Other family member (18 yrs & older)

Signature: Date:
Other family member (18 yrs & older)

Signature: Date:
Other family member (18 yrs & older)

WARNING!! Title 18, Section 1001 of the United States Code makes it a criminal offense to make willful false statements or presentation to any
Department or Agency of the United States as to any matter within its jurisdiction. Providing false statements or information will result in
termination of assistance and eligibility, and may be subject to criminal prosecution.

SHRA Annual Recertification Packet Page 13 of 15 Revised 04.22.2024 MO

 SHRA-AUTHORIZATION FOR RELEASE OF INFORMATION

Housing Choice Voucher Program, 630 I Street, Sacramento, CA 95814

CONSENT: I authorize and direct all listed below to release to THE SACRAMENTO HOUSING & REDEVELOPMENT AGENCY, the Public Housing
Authority (PHA), any information or materials needed to complete and verify my application, eligibility for assistance, and continued eligibility under the
Housing Choice Voucher, Mod-Rehab, Low-Income Public and Indian Housing and/or other housing assistance program(s). I understand and agree that
this authorization or the information obtained pursuant to its use may be given to and used by the Department of Housing and Urban Development (HUD) in
administering and enforcing program rules and policies.

I also consent for HUD or the PHA to release information from my file about my rental history to HUD credit bureaus, collection agencies, or future landlords.
This includes records of my payment history, and any violation of my lease or PHA policies.

INFORMATION COVERED: I understand that depending on program policies and requirements, previous or current information regarding my household or
myself may be needed. Verifications and inquiries that may be requested include but are not limited to:

Identity and Marital Status Credit Activity Medical or Childcare Allowances Residences and Rental Activity
Household Composition Criminal Activity Employment Income/Assets

I understand that this authorization cannot be used to obtain any information about me that is not pertinent to my eligibility for and continued participation in
a housing assistance program.

GROUPS OR INDIVIDUALS THAT MAY BE ASKED: The groups or individual that may be asked to release the above information (depending on program
requirement), include but are not limited to:

Landlords (including Public Past and Present Employers Veterans Administrations Banks and other Financial
Housing Agencies) Institutions
Schools and Colleges Welfare Agencies Retirement Systems Court Clerks
Medical Facilities Credit Providers Credit Bureaus State Unemployment Agencies
Postal Office Law Enforcement Agencies Social Security Administration Medical & Childcare Providers
Utility Companies Foster Care Providers Support & Alimony Providers Workers’ Compensation Payers
Trust Funds Department of Motor Vehicles Support Service Providers Insurance Agencies

COMPUTER MATCHING NOTICE AND CONSENT: I understand and agree that HUD or the PHA may conduct computer-matching programs to verify the
information supplied for my application or recertification. If a computer match is done, I understand that I have a right to notification of any adverse
information found and a chance to disprove incorrect information. HUD or the PHA may in the course of its duties exchange such automated information
with other Federal, State, or local agencies, including but not limited to: State Employment Security Agencies, Department of Defense, Office of Personnel
Management, U.S. Postal Service, Social Security Administration, State & County welfare and food stamp agencies.

CONDITIONS: I agree that this authorization is effective for fifteen months from the date signed. I understand that I have a right to review my file and
correct any information that I can prove is incorrect.

________________________________________ ________________________________________ ________ ______________________

Signature – Head of Household Print Name – Head of Household Date

________________________________________ ________________________________________ ________ ______________________

Signature Spouse/Co-Head Print name Spouse/Co-Head Date

________________________________________ ________________________________________ ________ ______________________

Signature – other adult Print Name – other adult Date

________________________________________ ________________________________________ ________ ______________________

Signature – other adult Print Name – other adult Date

__________________________________ ________________________________________ ________ ______________________

Signature – other adult Print Name – other adult Date

________________________________________ ________________________________________ ________ ______________________

Signature – other adult Print Name – other adult Date

SHRA Annual Recertification Packet Page 14 of 15 Revised 04.22.2024 MO

 Notice of Reasonable Accommodations for Participants and
Participant Families with Disabilities

(YOU MUST READ AND SIGN)

The Sacramento Housing Authority is a Public Housing Authority (PHA) that administers the Housing
Choice Voucher (HCV) rent subsidy program to eligible families, which includes elderly, disabled, and
single people. The PHA cannot discriminate against applicants on the basis of race, religion, sex,
national origin, disability or familial status. In addition, the PHA has a legal obligation to provide
“reasonable accommodations” for participants of the HCV program if they or any family members have a
disability.

A reasonable accommodation is a change, exception, or adjustment to a rule, policy, practice, or service

that may be necessary for a person with a disability to have an equal opportunity to use and enjoy a
dwelling, include public and common spaces. Examples of reasonable accommodations might include,
but are not necessarily limited to:

Consider the special problem of ability to locate an accessible unit when considering requests for
an extension of Housing Vouchers by eligible individuals with a disability.
Permitting an outside agency to help a participant with a disability meet the PHA’s continued
eligibility criteria for the HCV program.

A participant family that has a member with a disability must still be able to meet essential obligations of
tenancy, i.e., they must be able to pay rent, to care for their unit, to report required information to the
Housing Authority, to avoid disturbing their neighbors, etc., but there is no requirement that they be able
to do these things without assistance.

If you or a member of your family have a disability and think you might need or want a reasonable
accommodation, you may request it at any time.

Participants are advised that their failure to disclose that they or a family member is disabled may result
in the loss of certain financial deductions in the calculations of rent.

Certification of Understanding
I have read and understand the above notice regarding “Reasonable Don’t
Accommodations for Participants or Participant Families with Disabilities.” forget to
complete
this
portion.
___________________________________________ ____________________________ ___________________
Signature of Head of Household Print Name of Head of Household Date

SHRA Annual Recertification Packet Page 15 of 15 Revised 04.22.2024 MO