Signed by:

Owner or owner's representative

Name Signature _____________________________ ___________________________ Title Date

Warning: Under 18 U.S.C. 1001, whoever willingly makes or uses a document or writing he/she knows has any false or fraudulent statement or entry, in any matter under the jurisdiction of any department or agency of the United States, may be fined up to $10,000 or imprisoned for up to five years, or both.

form HUD-90104 12/2007

1 of 6

U.S. Department of Housing OMB Approval No. 2502-0204 (exp. 03/31/2014) and Urban Development Office of Housing Federal Housing Commissioner

Exception to Limitations on Admission of Families

IMPORTANT: At a minimum, requests for exceptions must include the supporting justification listed below. Situations (1) through (6) are described in paragraph 3-7 D of this handbook.