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OMB Control # 2502-0581 EXH t%T(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 ❑ Assist with Recertification Process ❑ Unable to contact you ❑ Change in lease terns ❑ Termination of rental assistance ❑ Change in house rules ❑ eviction from unit ❑ Other: ❑ Late payment of rent 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 cue, 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 fort 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. ❑ Check this box if you choose not to provide the contact information. Signature of Applicant Date The intonmation no ecton vraivo,ens contained in this torn were submitted m d¢ Office of Management and Badger (OVE) under thePapew rk Reduction Alt of 1995 t44 U.S.C. 3501-3520). The public repeating burden is estimated at 15 natures pet response including the time tier reviewing instructions, searching existing data samces, eatherine and maintaining the data needrd, and enmpletiag and reviewingthe cAlection of intnrmation. Section 644 of the Housing and Conai iryDevelegnnent Act of 1992(42U.SC'.13604) imposed on HUD the oh liotiohn no require housin,providers participating in HUD's assured housing programs to pnmide any individual arrands appl}ing tot occupancy in HIID-assisted housing with the option to Include in the algrlication for occupancy the name, address, telephone nnmba', and other relevant information ofa tastily member, a rid. or person associated with a social, health, ad wocacy, or shnilar organization. The (itjective ofpiovidine such inturmation is to tacilimde contact by the housing provider with the person or organization identified by the tenant to assist in pu) - ding any delivery of services a special care to the tenant and assist with resolving any tenancy issues arising daring the tenancy of auch detract This supplennental application information is to be mainmined by the housing provider and maintained as amfidendal i durication_ Pro,iding the infonmatinn is basic to he operations lithe HUD Assisted -Housing Program and is voluutuv U supports statnmry requiremenus and program and management wntmis that prevent hand, waste and mismanagement In accordance with the Paperwork Redaction Act, at agencynuy not ennduct m'sp noic. and a person is not required to rcghond to, a collection of infonuation, unles, the collection displays a cra City Council 31 — 27 7/20/2021 Privacy SannunC Public I.aw 102-550, aldcairea the nepartment of Housing and Urban nerclopment (HUD) to Collectall the information (excepuhe Social Security Number (SSN)j which will be toed by HUD m protect disbhusemenl data from fmudulem actions_ Page 20 of 29 Form HUD- 9211116 05,09)