Records of Family Circumstances/Family Composition/Allowances

• Work permit

• Statement of disability

• Social security record

• Adoption papers

• Income tax returns

• Legal documents showing formal adoption being pursued

• Birth certificates

• Copies of medical bills

• Social security cards/alternative documents

• Payment receipts for dependent care, child care, etc.

HUD Occupancy Handbook Exhibit 4-1

8/13

1

Race and Ethnic Data Reporting Form

U.S. Department of Housing and Urban Development Office of Housing

OMB Approval No. 2502-0204 (Exp. 03/31/2014)

Name of Property Project No. Address of Property

Name of Owner/Managing Agent Type of Assistance or Program Title:

Name of Head of Household Name of Household Member