ࡱ> ?A@%` bjbjٕ 'jjj8$ (222V"x $Ch~&44"&22;X222 0˹{j|Q0)))&&HXD d ;  I (We),_________________________________________________, certify that I (we)  FORMCHECKBOX  have  FORMCHECKBOX  have not claimed_______________________________________ (student name) as a dependent on my/our tax return for ___________________(year). I (We) also certify that I (we) will be providing financial assistance in the amount of $________________ per month during the next 12 months. I (We) certify that the information provided herein is true and complete to the best of my (our) knowledge. PENALTIES FOR MISUSING THIS FORM Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government, HUD, the PHA and any owner (or any employee of HUD, the PHA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the PHA or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7) and (8). Violation of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8). Signature______________________________ Print Name____________________________ Date______________________________________ Signature______________________________ Print Name____________________________ Date______________________________________     Sample Student Certification of Dependent Status and Financial Assistance Provided  Page  PAGE 1 of  NUMPAGES 1 Revised 3/2008 ;QRSTbcdjkyz{  a b c s x   ) * + ޺ެޥޑ{ughW@5B*CJ^Jph hW@CJh}h}OJQJ^Jh}h}@&h}h}B*fHphq h}hYSjth}h}Ujh}h}Ujh}h}U h}hW@h} h}h}hYShW@#hh}CJOJQJ\^JaJ&RS b c   * $Ifgds]gd}gdW@$hx]h^`xa$gd}* + , ~ $Ifgdy $$Ifa$gdslkd$$Ifl    $$  0    $4 lalp yts+ , g &8<ACEOPQRcdgm   ¾ɾɷɷɷɷ³³³¾ɷɷɷɷɷɷɷhyh58jh58Uh}hYSOJQJ^JhYS h}hW@h} h}h}hW@h}h}OJQJ^JhW@CJ^JhyhyCJaJhyhW@CJaJhW@CJ^J6PQR  gd}gdW@]gd}\kd$$Ifl    $$0    $4 lalyts   5hijklgd}$hx]h^`xa$gdYS$a$gdYSSghijklmstz{|}ȹ||vvih}hYSOJQJ^J hy0Jhy0JmHnHu hl0Jjhl0JUhljhW@UmHnHuh58hyh=hYShYSCJOJQJ\^JaJ#hhYSCJOJQJ\^JaJ'hhYS@CJOJQJ\^JaJ!hy@CJOJQJ\^JaJ21h:p}/ =!"#$% nOd5$VhˮPNG  IHDRHLsBIT'$ cmPPJCmp0712`IDATXG1hH_>dH…PH-t٥s:K+¹ w  G\܂],D/\4E@St39a;Yyϼ7ofAakR =oxVKB"d'ZT>a@T.h%E60T/{bPZ#B$rI ʀr. L_yʌT"Q t9S ͉**@Ar5Gs+Pfy$(B?Ɍy%8r:7= " څ0](xF狂f9r#J!H4:͊wIT_H%Xū.jf$)L9N-يd9O5G!)7[l"Ĭ͖'@GOR(` `E.!'Ϲd'vqlb[.|zĬmhC0y7&Y y+K"RcڳEG_D~yL*ڵ/#8E<-ES$e="@:ܟGJ;k ?9rc0k|h쯊RCŖ" 2  0V0$rKPvL5Mc<^^j7{3wMX-JWZɭJÿnk^7ÿeͭϷkeQe,myxF0:;zG؝v&Z#䠡 ŲhGQ#)y1 P0p"(>QUiYy\!*)* @HB8]*"쎧Vaya\YQx*#<ӏ0bly32Ǘw\O/~ѼjQ~nwַOX% X]%FdoiDqt$Gi4ı6Z`_id՛V/ԬyD4랩v퀞a雚նNȱb]~4ӉD]M="G>yoJݏ֓p}Sbq46*PM$] 4FZ W'>seRiԽi53bf=5>3^?}JPp[%E76e uF0>윐MbەF&nٽ$r'_CL] A׏NIyJ@@kTHG4@^%2C]oߦIENDB`tDeCheck1tDeCheck2$$Ifl!vh5$#v$:V l  0    $5$4alp yts$$Ifl!vh5$#v$:V l0    $5$4alyts@@@ }NormalCJ_HaJmH sH tH f@f W@Heading 5,Block Label5$7$8$9D@&H$ 5CJaJDA@D Default Paragraph FontRi@R  Table Normal4 l4a (k(No List< @< }Footer  !CJaJ4@4 YSHeader  !.)@. l Page Number"RS bc*+,PQR    5hijl0000000000000000 0 00 0 000000000@0@0@00h00ZH00h00ZH00h00ZH00h00ZH00H00 T]@0@0@0`0 0 =Z@0 0]@0h00H00RS bc*+,PQR50000000000000000 0 00 0 0000000000000@0 00 ce+  *    ScjzG$G$lsuz!  /Xb$~;<@rK- ,b$d5$VhˮW4"@ (  f  C (Afheo100"`0(  B S  ?eB+UCheck1Check2Tkd{       c),.4KU      333333333      5ls}      srT ,s F /Pg( s:<. ? ?ie l!["$ n'75N5FU9=:|b;W@o@A"BxB.5L |NYS(LTVU VWY ['[<[o\`Fawb1~b4eIknWqrsJtPLxSOxuDzK{(}[53)znGu>P g+eMm}p{vya3Z.U%nahrAavK$7<Q!;l< y]#Ebl58]DrEo=d<F9K?H([rIiS*+  j@?_P@UnknownG: Times New Roman5Symbol?& : ArialArial"1hӦ&K 22!42QHX ?}2Student Certification of Mary Ross Mary RossOh+'0 $ D P \hpxStudent Certification of Mary RossNormal Mary Ross5Microsoft Office Word@@sE@ra{2՜.+,0 hp   Ross Business Development, Inc. Student Certification of Title  !"#$%&'()+,-./013456789<Root Entry Fp {>Data 1Table)WordDocument'SummaryInformation(*DocumentSummaryInformation82CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89qRoot Entry FZ{D@Data 1Table)WordDocument'  !"#$%&'()+,-./01CB SummaryInformation(*DocumentSummaryInformation8CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q՜.+,D՜.+,` hp   Ross Business Development, Inc. Student Certification of Title4 $,