DECLARATION

I, ____________________________________________________ hereby declare, under penalty of perjury, that I am (print or type first name, middle initial, last name):

______ 1. A citizen or national of the United States.

Sign and date below and return to the name and address specified in the attached notification letter. If this block is checked on behalf of a child, the adult who will reside in the assisted unit and who is responsible for the child should sign and date below.

________________________________________________ _________ Signature Date Check here if adult signed for a child: _______

HUD Occupancy Handbook Exhibit 3-5

8/13

1

Exhibit 3-5

4350.3 REV-1

• ______ 2. A noncitizen with eligible immigration status as evidenced by one of the documents listed below:

NOTE: If you checked this block and you are 62 years of age or older, you need only submit a proof of age document together with this format, and sign below:

If you checked this block and you are less than 62 years of age, you should submit the following documents:

• a. Verification Consent Format (see Sample Verification Consent Form in

• Exhibit 3-6).