I Office of Public and Indian Housing

Transcription

1 Housing Choice Voucher Program I Office of Public and Indian Housing Public reporting burden for this collection of information is estimated to average.08 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMB control number. Eligible families submit this information to the Public Housing Authority (PHA) when applying for housing assistance under Section 8 of the U.S. Housing Act of 1937 (42 U.S.C. 1437f). The PHA uses the information to determine if the family is eligible, if the unit is eligible, and if the lease complies with program and statutory requirements. Responses are required to obtain a benefit from the Federal Government. The information requested does not lend 1. Name of Public Housing Agency (PHA) 2. Address of Unit (Street address, Apartment number, City, State &Zip Code) 2b.Census Tract# 2c.Parcel ID # Pahokee Housing Authority 3. Requested Beginning Date of Lease 4. Number of Bedrooms 5.Year Constructed 6. Proposed Rent 7. Security Deposit Amount 8. Date unit available for inspection 9. Type of House/Apartment Single Family Detached Semi-Detached/Row House ^Manufactured Home DGarden/Walkup Elevator/High-Rise 10. If this unit is subsidized, indicate type of subsidy: Section 202 ^Section 221 (d)(3)(bmir) Home Tax Credit Section 236 (Insured or noninsured) Other (Describe, Including Any State or Local Subsidy) Section 515 Rural Development 11. Utilities and Appliances REMINDERS: Utilities must be on during the HQS Inspection. The unit may not be occupied by another tenant. The owner shall provide or pay for the utilities and appliances indicated below by an "O". The tenant shall provide or pay for the utilities and appliances indicated below by a "T". Unless otherwise specified below, the owner shall pay for all utilities and appliances provided by the owner. Item Heating Cooking Specify fuel type Natural gas Electric Oil Natural gas Electric Appliance Provided by Service Paid for by UTILITY INFORMATION MUST BE COMPLETED Water Heating Natural gas Electric Oil ACCURATELY. Other Electric Water Sewer Voucher Size Issued Trash Collection Air Conditioning Refrigerator Range/Oven Other (specify) 12. Number of Children under the age of six (6) to reside in the Household? (Circle the number)? (other) 13. Owner's Certifications. c. Check one of the following,..., i Lead-based paint disclosure requirements do not apply a. The program regulation requires the PHA to certify that the becauge this wgs bui, Qn Qr gfter Jgn 1 mq rent charged to the housing choice voucher tenant is not more ' ' Previous editions are obsolete Page 2 of 2 Form HUD (6/2003) Ref. Handbook

2 than the rent charged for other unassisted comparable units. Owners of projects with more than 4 units must complete the following section for most recently leased comparable unassisted units within the premises. Note: This section applies to multifamiiy properties only. The unit, common areas servicing the unit, and exterior painted surfaces associated with such or common areas have been found to be lead-based paint free by a lead-based paint inspector certified under the Federal certification program or under a federally accredited State or Tribal certification program Address and unit number Date Rented Rental Amount A completed statement is attached containing disclosure of known information on lead-based paint and/or lead-based paint hazards in the unit, common areas or exterior painted surfaces, including a statement that the owner has provided the lead hazard information pamphlet to the family. d. The owner certifies that property taxes for the unit are currently paid. 14. The PHA has not screened the family's behavior or suitability for tenancy. Such screening is the owner's own responsibility. b. The owner (including a principal or other interested party) is not the parent, child, grandparent, grandchild, sister or brother of any member of the family, unless the PHA has determined (and has notified the owner and the family of such determination) that approving rental of the unit, notwithstanding such relationship, would provide reasonable accommodation for a family member who is a person with disabilities. 15. The owner's lease must include word-for-word all provisions of the HUD tenancy addendum. 16. The PHA will arrange for inspection of the unit and will notify the owner and family as to whether or not the unit will be approved. 17. Print or Type Name of Owner or Owner Representative 18. Print or Type Name of Head of Household Signature Date Signature(Head of Household) Date Business Address Present Address of Family (street address, apartment no., city, state, zip) Primary Telephone Number Circle One: Primary Telephone Number Circle One: Home: Cell Work: Home: Cell Work: Secondary Telephone Number Circle One: Secondary Telephone Number Circle One: Home: Cell Work: Home: Cell Work: Fax Number Address Fax Number Address 19. Do you want the Housing Assistance Payment to go to someone other than the owners listed above? C]YES QNO If yes, the section below must be completed & the W-9 form must be filled out for the HAP Payee listed below. The IRS requires that the person/business who reports the income earned from this property on their income taxes, report their personal or business Social Security/Tax I.D. number. These names and numbers must match those on file with the IRS. The IRS may impose stiff penalties if incorrect information is submitted. The IRS requires that the Housing Assistance Payments Contracts be executed in the person or business name that is responsible for reporting the income earned from this unit on their taxes. Print Name of HAP Payee PAHOKEE HOUSINGAUTHORITY, INC. Primary Telephone Number Secondary Telephone Numt er FOR OFFICE USE ONLY: Business Address 465 FRIEND TERRACE, PAHOKEE, FL Fax Number Voucher Issued Date By HS: Onitial Address Voucher Expiration Date ^Voucher Extension End Date O Transfer d Term Unit Previous editions are obsolete Page 2 of 2 Form HUD (6/2003) Ref. Handbook

3 Padgett Island 899 Padgett Circle Pahokee, FL Pahokee Housing Authority Administrative Office 465 Friend Terrace Pahokee, FL Phone: Fax: Fremd Village 177 Shirley Drive Pahokee, FL REQUEST FOR TENANCY APPROVAL (RTA) PACKET Instructions for the property owner/agent: You must return this RTA packet with all of the required materials to the PHA. Incomplete packets will not be accepted. The PHA will not process your request until you submit all of the required documents listed below. For additional information about the program, please refer to our website at YOU MUST COMPLETE AND RETURN THE FOLLOWING FORMS CONTAINED IN THIS PACKET: Request for Tenancy Approval Disclosure of Information on Lead-Based Paint W-9 Form(Owner and Agent) YOU MUST ALSO SUBMIT THE FOLLOWING DOCUMENTS: Agreement Copy of the proposed Lease Agreement (unsigned) Valid photo identification If an agent will receive payments, an Owner/Agent Proof of Ownership Direct Deposit Authorization (New Owners Only)

4 Next Steps The PHA will review the RTA and supporting documentation. PHA will contact the owner to schedule an HQS inspection. Utilities must be operable at the time of inspection. Your proposed rent will be compared to rents charged for similar properties in the area to determine reasonableness. The PHA will also determine if the rent is affordable for the tenant. Once the unit passes inspection and rent is approved, the PHA will contact you to execute the HAP Contract. An executed lease with Tenancy Addendum and the signed HAP Contract must be received in order for payments to begin. Thank you for your cooperation. INSTRUCTIONS FOR COMPLETING THE ATTACHED REQUEST FOR TENANCY APPROVAL (RTA) Line 2 ' Address of Unit Enter the complete address of the rental unit, including an apartment number and zip code. Line 2b Census Tract # Enter the Census Tract # where the unit is located; visit for assistance. Line 2c Parcel ID # Enter the Parcel ID # where the unit is located; visit for assistance. Line 3 Requested Beginning Date of Lease v Enter the date (day/month/year) that you would like to rent your unit. Line 4 Number of Bedrooms Enter the number of bedrooms in the rental unit.

5 Li " e5 Une6 Line8 Li " e9 Year Constructed Proposed Rent Security Deposit Amount Type of House/Apartment Enter the year the rental property was originally built. Enter the amount of rent that you are requesting for the rental unit. Enter the amount, if any, you are requesting from the tenant for a security deposit. Enter the date (day/month/year) the unit will be ready for the Inspection Department to conduct an inspection. Identify the type of housing you are renting by checking one appropriate box. If there is a contract with another government agency to provide assistance to the building or families residing in the building, select the appropriate box. If not, leave it blank. LineU.iticsandAppiiances Lmcl2 SP" Select 13a asr If Complete the utility chart by enter an '0' for utilities that will be paid by the owner and a 'T' for utilities that will be paid by the tenant. This information much match the lease. the number of children under 6 that will reside in the household. Circle 0 if there are not any. the rental property contains 4 or more units, enter the address, rental dates, and rental amount charged for other units in the building. If the property contains less than 4 units, this section does not apply. By signing the RTA, you are affirming that you are not related to any family members in the rental unit. Select 1 of the 3 options to indicate if lead-based requirements do not apply, have been tested, or - ^:"- Lead that lead-based hazards are disclosed. * owner's edification-proper, y By signing the RTA, you are certifying that the property taxes are current

6 Owner Information Head of Household Information Payment information Include an owner signature, address, and valid contact information so that you can be contacted to schedule the inspection. The Head of Household for the rental family must sign the RTA and enter their current contact information. Select the 'YES' checkbox if the HAP payment should go to someone other than the owner/agent. Enter the name and contact information for the HAP Payee. Accuracy and completeness of the attached RTA is very important! Your request WILL NOT be accepted if any of the required fields are not completed. Please call PHA at if you have any questions.

7 RTA ADDENDUM 1. Is the Unit Handicap accessible? QYES QNO 2. Number of Bathrooms 3. Telephone # to call to schedule inspection I ) 4. Telephone # to call to enter unit day of inspection and/or gate code if applicable [ ) 5. Number of children under the age of six (6) who reside in the household? 6. Please select all that are applicable to your unit. Parking: I I Assigned Q Unassigned Q] Carport Q Garage Exterior: I I Balcony Q Deck Q Patio [[[] Porch Q Driveway Q Street Q None Amenities: Q Garbage Disposal Q Dishwasher Q Cable Q Pool Q] Pest Control Q] Security System I I I Lawn Care Q Ceiling Fans Q Washer/Dryer Hookups Q Washer/Dryer in Unit I Washer/Dryer in Complex Q Microwave (in addition to Range) I I Fenced Yard Q Gated Community Q Window/Wall A/C Q Central AC Additional Type of House/Apartment:\ I Single Room Occupancvl I Independent Group Resident (Assisted Living Facility) Owner/Landlord and Tenant acknowledge that: The information above is true and accurate. Falsifying information may result in program termination for both parties. Print Name of Tenant Print Name of Owner/Landlord Tenant Signature Owner/Landlord Signature Date Date Tenant Owner/Landlord

8 Major Areas of Unit Housing Choice Voucher Program Housing Quality Standards Landlord Self-Inspection Checklist Question to Ask Repairs Needed Electricity 1. Do all fixtures and outlets work? 2. Is there lighting in common hallways and porches? ro o "E CO JC o <D U) c 15 3 Q. HVAC Bathroom Kitchen Other 3. Are all outlets, light switches, and fuse boxes properly covered with no cracks or breaks in the plates or doors? 4. Are electric fixtures securely fastened without hanging or exposed wires? 5. Does the unit have a properly working & installed Ground Fault Circuit Interrupter (GFCI) Outlet? 6. Are all 3 prong electrical outlets grounded? 7. Are all utilities on the day of the inspection? 8. Is there permanently installed and properly operating heating equipment? 9. Is toilet securely fastened with no leaks or gaps and flushed properly? 10. Sink - Is there hot and cold running water, proper drainage, and no leaks? 11. Bathtub/shower - Is there hot and cold running water, proper drainage and no leaks? 12. Is bathroom vented with either a working exhaust fan or an exterior window? 13. Sink - Is there hot and cold running water, proper drainage, and no leaks? 14. Is there a fully working stove or cook top and oven? 15. Do all burners on the stovetop ignite, does the oven work, and are all knobs presents or controls working? 16. Does the refrigerator cool/freeze properly? 17. Is there a fully working refrigerator? 18. Does the hot water heater work properly? 19. Does the water tank have a properly installed pressure relief valve extension tube? 20. Is the bathroom free of any sewer odor or drainage problem?

9 Major Areas of Unit Wall Condition Ceiling Condition Floor Condition Housing Choice Voucher Program Housing Quality Standards Landlord Self-Inspection Checklist Question to Ask 21. Are walls free or air and moisture leaks, large holes and cracks? 22. Are ceilings free of air and moisture leaks, large holes and cracks? 23. Are floors free of weak spots or missing floorboards? 24. Are floors free of tripping hazards from loose flooring or covering? Repairs Needed 3 c "E D (1) + > X HI +J "E D Cabinets/Interior Doors Security Health & Safety Windows Other 25. Are cabinets securely fastened to the wall? 26. Is there space for food preparation and storage? 27. Are all doors securely hung? 28. Is there free and clear access to all exits? 29. Do all exterior and common area doors have properly installed and working locks? 30. Do first floor windows and windows opening to a stairway, fire escape, or landing have locks? 31. Is there a working smoke detector on each level of the unit? 32. Are smoke detectors installed outside or near bedrooms? 33. Is the unit free of insect or rodent infestation? 34. Is there at least one exterior window in each bedroom and in the living room? 35. Do windows open, close, and lock properly? 36. Is the unit free of cracked, broken, or leaky windows? 37. Is the roof free of leaks? 38. Are gutters (if required) attached firmly? 39. Are exterior surfaces in a condition to prevent moisture leaks and rodent infestation? 40. Is the chimney secure and flue tightly sealed with no gaps? 41. Is the house/building's foundation sound?

10 Major Areas of Unit Housing Choice Voucher Program Housing Quality Standards Landlord Self-Inspection Checklist Question to Ask 42. Are openings around doors and windows weather-tight? 43. Are sidewalks free of tripping hazards? Repairs Needed W re re +-> w Stairways: Interior & Exterior Interior/Exterior Building 44. Are all handrails properly secured? 45. Is there a handrail when there are 4 or more consecutive steps? 46. Are stairs free of loose, broken, or missing steps? 47. Are stairways free to tripping hazards? 48. Are there secure railings on porches, balconies, and landings 30" or higher? 49. Is the unit free of debris outside and inside the units? 50. Are there covered waste disposal receptacles? O s: 51. Units built before 1978 with child residents under 6 yrs old must be free of chipping, peeling, flaking, chalking or cracking painted surfaces, including windows, window seals, doorframes, walls, ceilings, porches, and all other interior/exterior painted surfaces. NOTES NOTICE: This checklist is meant solely as a guide to help you prepare for the HCV HQS inspection, influence final HQS inspection findings cited by PHA's inspector Self- inspection results do not determine or

11 DIRECT DEPOSIT FREQUENTLY ASKED QUESTIONS 1. Q: Is the option available for tenants? A: No, this option is currently only being extended to owners. 2. Q: How do I set up direct deposit? A: Please complete and return the following documents to our office: 1) Authorization agreement for direct deposit 2) W-9 3) Copy of voided check or a statement from bank specifying the account name, type of account, routing number, and account number. 3. Q: When will direct deposit take effect? A: Please allow 60 days for processing. 4. Q: How will I know how much my HAP payments will be once direct deposit is set up? A: You will receive an ACH statement each month reflecting the amount of the HAP payment and the tenant the payment was made for. 5. Q: Is it mandatory? A: Yes. This is the only method of payment available to remit subsidy payments to owners/landlords. 6. Q: What if the name on my bank account is different than the name on my HAP check? A: In order to process your request for direct deposit, the name on the bank account, the authorization agreement, and the W-9 must match the name on the vendor account in our system of record. If your name has changed, you must submit proof of a name change and a completed a vendor change form before we can proceed with processing your request for direct deposit. 7. Q: Can I split the direct deposit between different bank accounts? A: Unfortunately, we do not have that capability. We can only deposit funds into one account. 8. Q: Can I put both me and my spouse's name on the W-9 since we file taxes jointly? A: For IRS tax reporting purposes, you only need to list the name on the W-9 and authorization agreement forms that is associated with the TIN or SSN reflecting on your vendor account.

12 9. Q: When will the deposit be made each month? A: The funds will be scheduled for deposit on the 1 st of each month. When the funds will be available to you depends upon your financial institution. 10. Q: What if I change bank accounts? A: You will be required to complete a new authorization agreement form for direct deposit identifying that it is a change request and provide a voided check or statement from the bank for the new bank account.

13 PAHOKEE HOUSING AUTHORITY, INC. Padgett Island Office 899 Padgett Circle Pahokee, FL Administrative Office 465 Friend Terrace Pahokee, FL (561) FAX (561) Fremd Village 401 Shirley Drive Pahokee, FL March 19,2013 To: Property Owners/Agents and Public Housing Agencies Effective June 1, 2013, Pahokee Housing Authority will be converting Housing Assistance Payments (HAP) to Direct Deposit for all property owners/agents and public housing agencies. Director Deposit payments are convenient, faster, safe, secure, and reliable and also save cost on mailing and postage. More importantly, this efficiency measure is part of our continuing effort to streamline business processes and allows HAP to be deposited directly into your bank account. Paper checks will be processed for HAP until the Payee establishes a Direct Deposit account and the account is tested to ensure accuracy of deposit. In the event that the payee chooses not to convert to Direct Deposit, Pahokee Housing will continue to issue paper checks only until the current contract end date. If the Payee has not converted by the end of the contract term, the tenant will be issued a new voucher and asked to relocate. Enclosed an Authorization Deposit form and. a new W-9 Form for your perusal. Monthly payment notifications send out by only. Please provide valid address. Please complete the forms and return them to our office in the enclosed self-addressed envelope, by April 8, Reply to: Section 8 Department Pahokee Housing Authority, Inc. 465 Friend Terrace Pahokee, Fl Should you have any questions, you may contact Ms. Eleanor Babb, Section 8 Coordinator, at , ext. 15. Satya} l Polineni Asst. Executive/Finance Director Enclosures: Director Deposit Form Terms and Conditions-Direct Deposit W-9 Form

14 Pahokee Housing Authority Pahokee Housing authority ' 465 Friend Terrace Pahokee, FL AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT I (we) hereby authorize Pahokee Housing Authority to initiate credit entries to my (our) account in the financial institution named below and authorize the financial institution to credit the same to my (our) account. This authorization is to remain in effect unless revoked by the vendor in writing to the Pahokee Housing Authority. Account changes must be reported to Pahokee Housing Authority thirty (30) days prior to the actual change. Please complete the following information and attach a voided check (If no voided check is available, have the bank stamp or provide a letter verifying account information) SECTION 1 - (To be completed by vendor) TYPE OF TRANSACTION (check one): ADD (new) CHANGE DELETE SECTION 8 LANDLORD? YES NO FEDERAL TAX ID OR SOCIAL SECURITY NUMBER:. MAILING ADDRESS: CITY, STATE, ZIP: VENDOR NAME: PHONE NUMBER: ADRESS: PAYEE PRINTED NAME PAYEE SIGNATURE CO-PAYEE PRINTED NAME CO-PAYEE SIGNATURE SECTION 2 - (To be completed by financial institution) DIRECT DEPOSIT TO BE MADE TO FINANCIAL INSTITUTION NAME: ; : MAILING ADDRESS:! CITY, STATE, ZIP:, TELEPHONE NUMBER: : TYPE OF ACCOUNT: CHECKING Q SAVINGS Q. BANK ROUTING NUMBER (The first nine digits prior to the account number in the bottom left corner of the check) Please Note: Some banks have different routing numbers for ACH or Direct Deposit BANK ACCOUNT NUMBER: BANK STAMP: SECTION 3 - (To be completed by Pahokee Housing Authority Finance Division) DATE RECEIVED: / / ACH BANK CODE: VENDOR NUMBER: PROCESSED BY: DISBURSEMENTOFFICER APPROVAL BY: ACH PROCESSED: SIGNATURE: SIGNATURE: IMPORTANT REMINDER! ATTACH A VOIDED CHECK

15 TERMS AND CONDITIONS FOR DIRECT DEPOSIT PARTICIPATION The tax identification and bank account information will remain confidential to the extent provided by law and are needed to make Direct Deposit payments. Failure to provide the requested information will affect the processing of this form and will likely prevent the receipt of payments through Direct Deposit. This form authorizes the Pahokee Housing Authority Housing Authority to initiate credit and if necessary, debit entries and adjustments for any credit entries in errorto the account indicated at the Depository Financial Institution named and to credit or debit the same from such account. This authority will remain in effect until cancelled in writing. Further, the origination of Automated Clearing House (ACH) transactions to the account must comply with the provisions of the state and federal law and regulations. Information Found on Checks Most of the information needed to complete the Direct Deposit Authorization Form is printed on your checks. Be sure that the payee's name is written exactly as it appears on the check and that the current address is shown. Cancellation This authorization remains in effect until cancelled by the payee through written notice to the Pahokee Housing Authority-Finance Department 465 Friend Terrace, Pahokee, FL Upon cancellation by the payee, the payee should also notify the receiving financial institution that the authorization has been cancelled. The Pahokee Housing Authority expressly reserves the right to discontinue Direct Deposit at any time. This authorization may be cancelled by the financial institution by providing the payee a written notice 30 days in advance of the cancellation date. However, a cancellation by the financial institution for reason of fraud shall be effective immediately. The payee must immediately advise the Pahokee Housing Authority if the authorization is cancelled by the financial institution. Violation of these terms and conditions may cause termination of participation in Direct Deposit. Financial Institution Information and Certification Provide the exact format of the payee's account number and account title as it appears in the records of the financial institution, If the financial institution acts as an agent for the payee and the accounts are not checking or savings accounts, the payee and the financial institution should provide explicit written instructions (unique prefix, alpha character, etc.) as an attachment to the authorization form. The Bank Representative may make corrections on the authorization form, in ink, and then sign the form attesting to the accuracy of the information. Change Receiving Financial Institutions The payee's Direct Deposit Authorization will remain in effect until withdrawn in writing with sufficient notice to the Pahokee Housing Authority to allow adequate time to effect termination. The payee may change the financial institution receiving the Direct Deposit. To effect this change, notification of the change must be made in writing to the Pahokee Housing Authority - Finance Department by the payee, or an authorized representative. Changes to the account information will cause the original authorization to be immediately inactivated. A new Direct Deposit Authorization form must be completed with the new information and verified by the new financial institution. It is recommended that the payee maintain the previously authorized account until the transition is complete, i.e., after the payee verifies receipt of the Direct Deposit payment in accordance with the new authorization instructions. False Statements or Fraudulent Claims Anyone who misrepresents or falsifies essential information to receive payment may upon conviction be subject to fine and imprisonment under the applicable Federal and State laws. Federal law provides a fine or imprisonment for not more than five (5) years or both for presenting a false statement or making a fraudulent claim. Agency. Signature. Date PAHOKEE HOUSING AUTHORITY 465 FRIEND TERRACE PAHOKEE, FL (561)

16 Form (Rev. December 2011) Department ol lha Treasury Internal Revenue Service Name (as shown on your incomo lax return) Request for Taxpayer Identification Number and Certification Give Form to the requester. Do not send to the IRS. Business name/disregarded entity name, If different from above 1 o E c H d 0 Check appropriate box (or federal tax classification:. Individual/sole proprietor O C Corporation [3 S Corporation CU Partnership Q Trust/estate Q Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, Partnership) D Other (see Instructions) K Address (number, street, and apt. or suite no.- <u a W City, state, and ZIP code Requester's name and address (optional) O ExempI payee List account number(s) here (optional) Taxpayer Identification Number (TIN) Enter your TIN In the appropriate box. The TIN provided must match the name given on the "Name" line to avoid backup withholding. For Individuals, this Is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I Instructions on page 3. For other entitles, It Is your employer Identification number (EIN). If you do not have a number, see How to get a TIN on page 3. ' Note. If the account is In more than one name, see the chart on page 4 for guidelines on whose number to enter. ' Certification Social security number Employer identification number Under penalties of perjury, I certify that:. 1. The number shown on this form Is my correct taxpayer identification number (or I am waiting for a number to be Issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt-from backup withholding, or (b) I have.not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and ' ' 3. I am a U.S. citizen or other U.S. person (defined below). ' Certification Instructions, You must cross out Item 2 above If you have been notified by the IRS that you Bre currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, Item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an Individual retirement arrangement (IRA), and generally, payments other than Interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on pagb 4. Sign Here Signature of U.S. person General instructions Section references are to the Internal Revenue Code unless otherwise noted. Purpose of Form A person who Is required to file an Information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, Income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9 only If you are a U.S. person (Including a resident alien), to provide your correct TIN to the person requesting It (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding If you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income. Date* Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form If It is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person If you are: An individual who Is a U.S. citizen or U.S. resident alien, A partnership, corporation, company, or association created or organized In the United States or under the laws of the United States, An estate (other than a foreign estate), or A domestic trust (as defined In Regulations section' ), Special rules for partnerships. Partnerships that conduct a trade or business In the United States are generally required to pay a withholding tax on any foreign partners' share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner Is a foreign person, and pay the withholding tax. Therefore, If you are a U.S. person that Is a partner in a partnership conducting a trade or business In the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership Income. Cat. No X Form W-9 (Rev ) -

17 Pahokee Housing Authority, Inc. 465 Friend Terrace Pahokee, FL (561) FAX (561) SECTION 8 LANDLORD CERTIFICATION RE: Street Address of Assisted Unit City/Town State Zip OWNERSHIP OF ASSISTED UNIT I certify that I am the legal or the legally-designated agent for the above referenced unit, and that the prospective tenant has no ownership interest in this dwelling unit whatsoever. APPROVED RESIDENTS OF ASSISTED UNIT I understand that the family members listed on the dwelling lease agreement as approved by the Housing Authority are the only individuals permitted to reside in the unit. I also understand that I am not permitted to live in the unit while I am receiving housing assistance payments. HOUSING QUALITY STANDARDS I understand my obligations in compliance with the Housing Assistance Payments Contract to perform necessary maintenance so the unit continues to comply with Housing Quality Standards. TENANT RENT PAYMENTS I understand that the tenant's portion of the contract rent is determined by the Housing Authority, and that it is illegal to charge any additional amounts for rent or any other item not specified in the lease which has not been specifically approved by the Housing Authority. REPORTING VACANCIES TO THE HOUSING AUTHORITY I understand that should the assisted unit become vacant, I am responsible for notifying the Housing Authority immediately in writing. COMPUTER MATCHING CONSENT I understand the Housing Assistance Payment Contract permits the Housing Authority or HUD to verify my compliance with the Contract. I consent for the Housing Authority and HUD to conduct computer matches to verify my compliance as they deem necessary. The Housing Authority and HUD may release and exchange information regarding my participation in the Section 8 program with other Federal and State agencies. ADMINISTRATIVE AND CRIMINAL ACTIONS FOR INTENTIONAL VIOLATIONS I understand that failure to comply with the terms and responsibilities of the Housing Assistance Payments contract is grounds for termination of participation in the Section 8 Program. I understand that knowingly supplying false, incomplete or inaccurate information is punishable under Federal or State Criminal Law. Signature of Landlord/agent Date WARNING: Title 18, US Code Section 1001, states that a person who knowingly and willingly makes false or fraudulent statements to any Department or Agency of the United States is guilty of a felony. State law may also provide penalties for false or fraudulent statements. IV

18 Pahokee Housing Authority, Inc. 465 Friend Terrace Pahokee, FL (561) FAX (561)