Item 31 - Emergency Housing Vouchers

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Page 4 TENANT INFORMATION FORM I certify that the information on this form is true and complete to the best of my knowledge and belief. I understand that I can be fined up to $10,000, or imprisoned up to five years if I furnish false or incomplete information. Date Part 4: Household Expenses Member Name Monthly Payment $ Verification Source Name and Address Documentation Attached NoYes Current Expense NoYes Member Name Monthly Payment $ Verification Source Name and Address Documentation Attached NoYes Current Expense NoYes Member Name Monthly Payment $ Verification Source Name and Address Documentation Attached NoYes Current Expense NoYes Member Name Monthly Payment $ Verification Source Name and Address Documentation Attached NoYes Current Expense NoYes Member Name Monthly Payment $ Verification Source Name and Address Documentation Attached NoYes Current Expense NoYes Allowance Type Allowance Type Allowance Type Allowance Type Allowance Type Member Name Monthly Payment $ Verification Source Name and Address Documentation Attached NoYes Current Expense NoYes Allowance Type Does any adult household member (age 18 or older) attend school full time? (If yes, provide current enrollment and financial aid information from registrar or admissions officer and enter contact information in the section below.) NoYes Does any member of your family have UNREIMBURSED expenses for care of a child age 12 or younger so that an adult family member can work?NoYes Review and update the following expense information relating to questions marked as Yes in the lines above.Additional expenses must be entered in the space provided below. Does any member of your family have UNREIMBURSED expenses for care of a person with disabilities so that an adult family member can work?NoYes ONLY complete the following if the head of household, spouse or co-head is age 62 or older, or has a disability. NoYes 1. 2. 3. 4. Part 5: Head of Household Must Sign this Form Certifying Accuracy of Information Provided Attach Additional Sheets if Necessary DOCUMENTATION REQUIRED:Provide documentation from Verification Source listing the monthly payment for each expense and check the Documentation Attached box for each expense. Does any member of your family have UNREIMBURSED medical expenses (i.e. Medical Insurance Premiums; Medical, Dental, or Optical Expenses; or Expenses for Prescription/Non Prescription Medicines (prescribed by a physician))? Name Page 11 of 29