To: Grand Management Services, 375 Park Ave, Suite 1, Coos Bay, OR 97420. This is a document testifying to accuracy or truth. The undersigned agrees as follows: I hereby notify Management that I have guests that will be visiting me and staying at my apartment during the day and/or night. These guests are identified below.
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I understand that if these individuals reside with me for more than 14 days and/or nights in a 45-day period, then their income may be considered in recalculating my rent contribution and in determining my eligibility for this housing. I understand that any permanent change in my household composition must be reported to and approved by Management. I also understand that I am responsible for the activities of these guests during their stay in my unit.
Verification: I hereby certify that the above information is true and complete to the best of my knowledge. Disclosure: This is a document testifying to accuracy or truth. Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false and fraudulent statements to any department of the United States Government. USDA Rural Development, the Department of Housing and Urban Development, Public Housing Authorities, the Oregon Housing and Community Services Department, and any owner (or any employee of these agencies or the owner) may be subject to the penalties for unauthorized disclosures or improper uses of information collected on the consent form. Use of the information collected based on this verification form is restricted to the purpose cited above. Any person who knowingly or willingly 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 unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 42 U.S.C. 208 (f), (g) and (h). Violations of these provisions are cited as violations of 42 U.S.C. 408 (f), (g) and (h). The Fair Housing Act prohibits discrimination in the sale, rental or financing of housing on the basis of race, color, religion, sex, handicap, family status, or national origin. Grand Management Services, Inc., is an equal housing opportunity provider.
