T-20 6/2018
Santa Ana Housing Authority
P.O. Box 22030, Santa Ana, CA 92702
(714) 667-2200
CRIMINAL HISTORY / SEX OFFENDER CERTIFICATION
As part of the screening process for the housing assistance program, all adult household members (18 years and older)
are required to complete this certification. The answers provided on this certification are used in part to determine your
eligibility for rental assistance benefits subsidized through the U.S. Department of Housing and Urban Development
(HUD). Any answers or documentation you provide as part of the application or recertification process are subject to
verification.
Failure to disclose any information and/or answer all questions in the application, including questions on this form, fully
and truthfully, may constitute grounds for denial of your application and/or termination of your rental assistance. In
addition, making false statements on this affidavit is a crime and may result in CRIMINAL PROSECUTION.
FULL LEGAL NAME________________________________________________________________________________
ANY MAIDEN NAMES OR ALIASES ___________________________________________________________________
DATE OF BIRTH ___________ SOCIAL SECURITY # _________________ DRIVER’S LICENSE # _____________
MM/DD/YY
CURRENT HOME ADDRESS (RESIDENCE) PREVIOUS HOME ADDRESS (if you’ve resided at the
current address less than 5 years)
Street: _____________________________ Street: _______________________________
City: _______________________________ City: _________________________________
State, Zip: __________________________ State, Zip: ____________________________
1. In the last three (3) years, have you been evicted from public housing or any other federally-assisted housing for
drug-related criminal activity? _______________________
2. In the last three (3) months, have you been convicted, arrested or evicted for drug-related criminal activity defined
by HUD, as the illegal manufacture, sale, distribution, or use of a drug, or the possession of a drug with intent to
manufacture, sell, distribute or use the drug? ____________________
3. In the last three (3) months, have you been convicted, arrested or evicted for abuse of alcohol? ______________
4. Are you currently using illegal drugs? ________________
5. Have you ever been convicted of drug-related criminal activity for the production or manufacture of
methamphetamine on the premises of federally assisted housing? ____________________
6. Are you subject to a lifetime registration requirement under a state sex offender registration program? _________
7. Have you ever committed fraud, bribery, or any other corrupt or criminal act in connection with any federal
housing program? __________
8. Are you a fugitive from justice? _____________________
9. Do you owe rent or other amounts to any PHA in connection with the HCV, Certificate, Moderate Rehabilitation or
public housing programs? _________ Are you still paying? ________
IF YOU ANSWERED “YES” TO ANY QUESTION ABOVE, PLEASE EXPLAIN IN DETAIL:
_______________________________________________________________________________________________________________________
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WARNING: TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSON IS GUILTY OF A
FELONY FOR KNOWINGLY & WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT
OR AGENCY OF THE UNITED STATES. MAKING FALSE STATEMENTS ON THIS DOCUMENT IS ALSO A FELONY
UNDER CALIFORNIA STATE LAW (PENAL CODE SECTIONS: 115, 118, 487, 532) AND MAY RESULT IN CRIMINAL
CHARGES INCLUDING PERJURY, GRAND THEFT, FILING FALSE DOCUMENTS WITH A PUBLIC OFFICE AND
OBTAINING MONEY UNDER FALSE PRETENSES.
I do hereby certify under penalty of perjury, that all of the information contained in this document is true and correct. I
understand and acknowledge that falsifying information on this certification may result in denial of admission into the
Housing Choice Voucher Program (Section 8) or immediate termination of my housing assistance subsidy and/or criminal
prosecution.
Signature: _____________________________________________________ Date: ___________________________
