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example of background check or criminal history form
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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? ________
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 : ___________________________