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Criminal DataYou will be required to complete and sign a release authorizing us to obtain a police record/criminal background check.1.2.3.Have you, or any member of the applicant household ever been arrested or convicted of a crime other than atraffic violation? Yes/No If yes, please explain the nature of the problem and who was involved:Are you and all other persons listed on the application currently on parole or probation? Yes No If Yes,please explain:Are you or any other persons listed on the application required to register on any sex offender list? Yes NoIf yes please explain:Notification of Applicant ResponsibilityIt is the responsibility of each applicant to notify the Clarksville Housing Authority, 721 Richardson Street, P. O. Box 603,Clarksville, TN 37041, in writing and/or in person within 10 days of the occurrence, each time the address changesfor the applicant family.Failure to keep this office informed of any and all changes of address will prevent contact by mail, and will leave us noalternative but to withdraw the application and remove the family from the Wait List. In the event this happens, if the WaitList is open, it will be necessary for the applicant to submit a new application, which will automatically assign the family anew application position. CHA will take affirmative steps to communicate with people who need services or informationin a language other than English.If a letter is mailed and returned by the post office, the application will be withdrawn automatically, unless a forwardingaddress is listed. When a forwarding address is listed the CHA will re-mail the letter.Certification of AccuracyI/We understand that this form is not an offer of housing. Based on this form, I/We should not make any plans tomove or end my present tenancy. I/We understand that it is my responsibility to inform the Clarksville HousingAuthority of any change of address, income, reasonable accommodation, preference and/or family compositionor my application will be withdrawn. I certify that the information I/We have given on this document is true andcorrect. I/We understand that any false statement or misrepresentations are criminal offenses punishable understate and federal laws. I also understand that false statements or information are grounds for rejection of myapplication or termination of tenancy or program participation. Warning: Title 39, of the Tennessee CodeAnnotated States that it is unlawful for any person to knowingly make, utter, or publish a false statement ofsubstance or aid or abet another person in making, uttering, or publishing a false statement of substance for thepurpose of influencing the agent to allow participation in any of its programs. A violation of the Section is aClass 3 Felony. WARNING: TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSONIS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRADULENT STATEMENTSTO ANY DEPARTMENT OR GENCY OF THE UNITED STATES.Signature of Co-ApplicantDateSignature of Other Adult (Anyone age 18 and over)DateSignature of ApplicantSignature of Other Adult (Anyone age 18 and over)Revised 10/2015DateDate

Authorization for the Release of Information/Privacy Act Noticeto the U.S. Department of Housing and Urban Development (HUD)and the Housing Agency/Authority (HA)PHA requesting release of information; (Cross out space if none)(Full address, name of contact person, and date)OMB CONTROL NUMBER: 2501-0014exp. 1/31/2014IHA requesting release of information: (Cross out space if none)(Full address, name of contact person, and date)Authority: Section 904 of the Stewart B. McKinney HomelessAssistance Amendments Act of 1988, as amended by Section 903of the Housing and Community Development Act of 1992 andSection 3003 of the Omnibus Budget Reconciliation Act of 1993.This law is found at 42 U.S.C. 3544.This law requires that you sign a consent form authorizing: (1)HUD and the Housing Agency/Authority (HA) to request verification of salary and wages from current or previous employers; (2)HUD and the HA to request wage and unemployment compensation claim information from the state agency responsible forkeeping that information; (3) HUD to request certain tax returninformation from the U.S. Social Security Administration and theU.S. Internal Revenue Service. The law also requires independentverification of income information. Therefore, HUD or the HAmay request information from financial institutions to verify youreligibility and level of benefits.Purpose: In signing this consent form, you are authorizing HUDand the above-named HA to request income information from thesources listed on the form. HUD and the HA need this informationto verify your household’s income, in order to ensure that you areeligible for assisted housing benefits and that these benefits are setat the correct level. HUD and the HA may participate in computermatching programs with these sources in order to verify youreligibility and level of benefits.Uses of Information to be Obtained: HUD is required to protectthe income information it obtains in accordance with the PrivacyAct of 1974, 5 U.S.C. 552a. HUD may disclose information(other than tax return information) for certain routine uses, such asto other government agencies for law enforcement purposes, toFederal agencies for employment suitability purposes and to HAsfor the purpose of determining housing assistance. The HA is alsorequired to protect the income information it obtains in accordancewith any applicable State privacy law. HUD and HA employeesmay be subject to penalties for unauthorized disclosures or improper uses of the income information that is obtained based on theconsent form. Private owners may not request or receiveinformation authorized by this form.Who Must Sign the Consent Form: Each member of yourhousehold who is 18 years of age or older must sign the consentform. Additional signatures must be obtained from new adultmembers joining the household or whenever members of thehousehold become 18 years of age.Original is retained by the requesting organization.U.S. Department of Housingand Urban DevelopmentOffice of Public and Indian HousingPersons who apply for or receive assistance under the followingprograms are required to sign this consent form:PHA-owned rental public housingTurnkey III Homeownership OpportunitiesMutual Help Homeownership OpportunitySection 23 and 19(c) leased housingSection 23 Housing Assistance PaymentsHA-owned rental Indian housingSection 8 Rental CertificateSection 8 Rental VoucherSection 8 Moderate RehabilitationFailure to Sign Consent Form: Your failure to sign the consentform may result in the denial of eligibility or termination ofassisted housing benefits, or both. Denial of eligibility or termination of benefits is subject to the HA’s grievance procedures andSection 8 informal hearing procedures.Sources of Information To Be ObtainedState Wage Information Collection Agencies. (This consent islimited to wages and unemployment compensation I have received during period(s) within the last 5 years when I havereceived assisted housing benefits.)U.S. Social Security Administration (HUD only) (This consent islimited to the wage and self employment information and payments of retirement income as referenced at Section 6103(l)(7)(A)of the Internal Revenue Code.)U.S. Internal Revenue Service (HUD only) (This consent islimited to unearned income [i.e., interest and dividends].)Information may also be obtained directly from: (a) current andformer employers concerning salary and wages and (b) financialinstitutions concerning unearned income (i.e., interest and dividends). I understand that income information obtained from thesesources will be used to verify information that I provide indetermining eligibility for assisted housing programs and the levelof benefits. Therefore, this consent form only authorizes releasedirectly from employers and financial institutions of informationregarding any period(s) within the last 5 years when I havereceived assisted housing benefits.ref. Handbooks 7420.7, 7420.8, & 7465.1form HUD-9886 (7/94)

Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form forthe purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs thatreceive income information under this consent form cannot use it to deny, reduce or terminate assistance without firstindependently verifying what the amount was, whether I actually had access to the funds and when the funds were received. Inaddition, I must be given an opportunity to contest those determinations.This consent form expires 15 months after signed.Signatures:Head of HouseholdDateSocial Security Number (if any) of Head of HouseholdOther Family Member over age 18DateSpouseDateOther Family Member over age 18DateOther Family Member over age 18DateOther Family Member over age 18DateOther Family Member over age 18DateOther Family Member over age 18DatePrivacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this informationby the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the FairHousing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants andparticipants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income andother information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your familywill pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoringHUD-assisted housing programs, to protect the Government’s financial interest, and to verify the accuracy of the information you provide.This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatoryinvestigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permittedor required by law. Penalty: You must provide all of the information requested by the HA, including all Social Security Numbers you,and all other household members age six years and older, have and use. Giving the Social Security Numbers of all household memberssix years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provideany of the requested information may result in a delay or rejection of your eligibility approval.Penalties for Misusing this Consent:HUD, the HA and any owner (or any employee of HUD, the HA or the owner) may be subject to penalties for unauthorized disclosures or improper uses ofinformation collected based on the consent form.Use of the information collected based on the form HUD 9886 is restricted to the purposes cited on the form HUD 9886. Any person who knowingly or willfullyrequests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not morethan 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, againstthe officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use.Original is retained by the requesting organization.ref. Handbooks 7420.7, 7420.8, & 7465.1form HUD-9886 (7/94)

CERTIFICATION OFU.S. Department of HousingDOMESTIC VIOLENCE,and Urban DevelopmentDATING VIOLENCE,SEXUAL ASSAULT, OR STALKING,AND ALTERNATE DOCUMENTATIONOMB Approval No. 2577-0286Exp. 06/30/2017Purpose of Form: The Violence Against Women Act (“VAWA”) protects applicants, tenants, andprogram participants in certain HUD programs from being evicted, denied housing assistance, orterminated from housing assistance based on acts of domestic violence, dating violence, sexual assault, orstalking against them. Despite the name of this law, VAWA protection is available to victims of domesticviolence, dating violence, sexual assault, and stalking, regardless of sex, gender identity, or sexualorientation.Use of This Optional Form: If you are seeking VAWA protections from your housing provider, yourhousing provider may give you a written request that asks you to submit documentation about the incidentor incidents of domestic violence, dating violence, sexual assault, or stalking.In response to this request, you or someone on your behalf may complete this optional form and submit itto your housing provider, or you may submit one of the following types of third-party documentation:(1) A document signed by you and an employee, agent, or volunteer of a victim service provider, anattorney, or medical professional, or a mental health professional (collectively, “professional”) fromwhom you have sought assistance relating to domestic violence, dating violence, sexual assault, orstalking, or the effects of abuse. The document must specify, under penalty of perjury, that theprofessional believes the incident or incidents of domestic violence, dating violence, sexual assault, orstalking occurred and meet the definition of “domestic violence,” “dating violence,” “sexual assault,” or“stalking” in HUD’s regulations at 24 CFR 5.2003.(2) A record of a Federal, State, tribal, territorial or local law enforcement agency, court, oradministrative agency; or(3) At the discretion of the housing provider, a statement or other evidence provided by the applicant ortenant.Submission of Documentation: The time period to submit documentation is 14 business days from thedate that you receive a written request from your housing provider asking that you provide documentationof the occurrence of domestic violence, dating violence, sexual assault, or stalking. Your housingprovider may, but is not required to, extend the time period to submit the documentation, if you request anextension of the time period. If the requested information is not received within 14 business days of whenyou received the request for the documentation, or any extension of the date provided by your housingprovider, your housing provider does not need to grant you any of the VAWA protections. Distribution orissuance of this form does not serve as a written request for certification.Confidentiality: All information provided to your housing provider concerning the incident(s) ofdomestic violence, dating violence, sexual assault, or stalking shall be kept confidential and such detailsshall not be entered into any shared database. Employees of your housing provider are not to have accessto these details unless to grant or deny VAWA protections to you, and such employees may not disclosethis information to any other entity or individual, except to the extent that disclosure is: (i) consented toby you in writing in a time-limited release; (ii) required for use in an eviction proceeding or hearingregarding termination of assistance; or (iii) otherwise required by applicable law.Form HUD-5382(12/2016)

2TO BE COMPLETED BY OR ON BEHALF OF THE VICTIM OF DOMESTIC VIOLENCE,DATING VIOLENCE, SEXUAL ASSAULT, OR STALKING1. Date the written request is received by victim:2. Name of victim:3. Your name (if different from victim’s):4. Name(s) of other family member(s) listed on the lease:5. Residence of victim:6. Name of the accused perpetrator (if known and can be safely disclosed):7. Relationship of the accused perpetrator to the victim:8. Date(s) and times(s) of incident(s) (if known):10. Location of incident(s):In your own words, briefly describe the incident(s):This is to certify that the information provided on this form is true and correct to the best of my knowledgeand recollection, and that the individual named above in Item 2 is or has been a victim of domestic violence,dating violence, sexual assault, or stalking. I acknowledge that submission of false information couldjeopardize program eligibility and could be the basis for denial of admission, termination of assistance, oreviction.Signature Signed on (Date)Public Reporting Burden: The public reporting burden for this collection of information is estimated toaverage 1 hour per response. This includes the time for collecting, reviewing, and reporting the data. Theinformation provided is to be used by the housing provider to request certification that the applicant ortenant is a victim of domestic violence, dating violence, sexual assault, or stalking. The information issubject to the confidentiality requirements of VAWA. This agency may not collect this information, andyou are not required to complete this form, unless it displays a currently valid Office of Management andBudget control number.Form HUD-5382(12/2016)

CRIMINAL BACKGROUND SCREENING REQUEST FORMInstructions: Complete this part of the form only if the individual is applying for admission to The Clarksville Housing Authorityas a family member or live-in aide. This page may be used to request a background check for an existing family member also.Individuals must be informed that a criminal background check is being conducted and results will be used in determiningadmission to or continued assistance.MEMBER'S NAMELast NameFirst NameM.I.Social Security Number:Date of Birth:Last Known Address:(Street Address Only – P.O Boxes not accepted)(City)(State)(Zip)PRIOR ARREST /CONVICTIONS LISTED ON PERSONAL DECLARATION FORM?IF YES,City/State or CountDescription of Offense/ChargeYESNOYear*Reason for requesting background check(existing member status only). Example: newspaper clipping etc.We thank you for taking the time to fill out this information and hope that you will always feel free to contacteither the Housing Authority or the Clarksville Police concerning drug activity in your neighborhood.Please read and sign below:I agree that we must rid our neighborhoods of illegal drugs and the people responsible for them. I understand thatthe information I have provided will be checked by the Housing Authority and/or the Clarksville Police. I will nothold the Clarksville Housing Authority or the Clarksville Police Department in any way liable for checking on theinformation which I have provided.I have been notified that a criminal record search will be performed and understand that the information TheClarksville Housing Authority obtains is to be used in the processing of my application for public housing eligibility.*Not necessary for existing tenants/members with a signed Release of Information Form).Applicant Signature /DateCo-Applicant Signature Date(To be completed by The Clarksville Housing Authority) CRIMINALBACKGROUND CHECK RESULTS- MEMBER/AIDE:1.Criminal Record Identified? Yes No Pending Court Date: / /Yes No 3. Sex Offender Register?Yes No 4. Felony Offender Register? Yes No 2.Active Warrants?5.Based on the Criminal Background information obtained, is the member/aideeligible for public housing per the ACOP? Yes No Records Checked by (Signature)DateRecords Reviewed by (Signature)To Be Completed By PHAMember Status: Waiting List MemberAdd New MemberRelationship to Head of Household: Spouse*Existing MemberLive in AideOtherDate

It is the responsibility of each applicant to notify the Clarksville Housing Authority, 721 Richardson Street, P. O. Box 603, Clarksville, TN 37041, in writing and/or in person within 10 days of the occurrence, each time the address changes for the applicant family.