Exhibit A.pdf

Form RD 3560-8 USDA-RURAL HOUSING SERVICE

TENANT CERTIFICATION

Form Approved (Rev. 04-06) OMB No. 0575-0189

PART I-PROJECT AND UNIT IDENTIFICATION

1. Effective Date

M M D D Y Y

2. Project Name 3. Borrower ID and Project Number 4. Unit Type 5. Unit Number

Initial Certification

Designate 60 Day Absence

Recertification

End 60 Day Absence

WARNING STATEMENT: Section 1001 of Title 18, United States Code provides, ''Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact, or makes any false, fictitious or fraudulent statements or representations, or makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined under this title or imprisoned not more than five years, or both.''

Modify Certification

Assign/Remove RA Tenant TransferVacate a Unit

Certification Expired & Eviction in Process

PART II-TENANT

HOUSEHOLD INFORMATION

STATEMENT REQUIRED BY THE PRIVACY ACT: Title V of the Housing Act of 1949 authorizes RHS to collect the information on this form. Your disclosure of the information is voluntary. However, failure to disclose certain information may delay the processing of your eligibility or rejection. RHS will not deny eligibility if you refuse to disclose your Social Security Number.

6. Tenant Subsidy Code (enter code)

0 - No Deep Tenant Subsidy This information is collected principally to determine eligibility for occupancy and to determine your tenant contribution for rent. However, the information collected may be released to appropriate Federal, State and Local Agencies, credit bureaus and Servicing agents when relevant to civil, criminal or regulatory proceedings or to enforce regulations by manual or automated verification procedures.

4 - Other Public RA 5 - Private RA 6 - HUD Voucher Round all monetary figures up to the nearest dollar at. 50 and above. 13. Minor, 14. Elderly,7 - Other Types at Basic Rent Disabled, DisabledOther Subsidy Indicator (leave blank if none, P-Partial or F-Full) Other Subsidy Amount (For Partial) $ Handicapped or Handi-or Full-Time7. Social Security No. 8. Household Member Name 10. Date of Birth 11. Race 12. Ethnicity capped Student 18

(Last, First and Middle Initial) MM DD YY or Older (Complete this only(Complete whenthis only householdwhen memberhousehold is amember Tenant or is not Co-Tenant the Tenant or a (Check Co-Tenant when coded above)

Choices for Race are:

1 - American Indian or

TotalAlaskan Native Elderly2 - Asian (Line 13)

8a. Number of Foster Children (if any)

Status3 - Black or African PART III- ASSET INCOMEAmerican

4 - Native Hawaiian or Pacific Islander 15. Net Family Assets (NOTE: If Line 15 is less than $5,000, enter zero on Line 16.)

16. Imputed Income from Assets (Bank Passbook Savings Rate (*

17. Income from Assets

5 - White Choices for Ethnicity are:

a - Hispanic/Latino b - Non-Hispanic Latino

) x Line 15.)

PART IV- INCOME CALCULATIONS

18. Income 19. Adjustments to Income

b. Soc. Sec., Pensions, etc,

a. $480 x total of Line 13

b. $400 if elderly status

c. Medical exceeding 3% of Line 18f.

(if elderly, handicapped or disabled)

d. Child Care

e. Other

e. Total Adjustments

f. Annual Income $

$20. Adjusted Annual Income (Line 18.f. minus Line, 19.e.)

PART V-INCOME LEVELS

MM DD YY

21. Number of Household Members 23. Date of Initial Project Entry

22. Current Eligibility Income Level (Enter Code) 24. Eligibility Income Level at Initial Project Entry (Enter Code)

PART VI- CERTIFICATION BY TENANT

I certify and acknowledge that if the Agency provides unauthorized assistance to the borrower/multi-family housing project owner for my benefit based on erroneous or fraudulent information provided in

MM DD YY b. Tenant Signaturea. Date:

MM DD YY d. Co-Tenant Signature

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0575-0189. The time required to complete this information collection is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

1 - Rental Assistance (RA)

d. Income Contributed by Assets (Greater of Line 16 or Line 17)

a. Wages, Salaries, etc.

c. Assistance

c. Date:

12a. Race Determina-tion Code

Choices for Race Det. Code:

C - Customer Provided E - Employee Observed

g. Household Has Exempt Income this tenant certification, I will reimburse the Agency for that unauthorized amount. If I do not, the Agency may use all remedies available to collect it, including those under the Debt Collection Act, to recover on the Federal debt directly from me.

Cotenant to Tenant

2 - Project Based Section 8 below

9. Sex

PART VII - PRELIMINARY CALCULATIONS

25. Adjusted Monthly Income (Line 20 ÷ 12)

26. Monthly Income (Line 18.f. ÷ 12)

a. $ x .30 = b. $

a. $ x .10 = b. $ $27. Designated Monthly Welfare Shelter Payment

28. Highest of Line 25.b., Line 26.b., or Line 27,

29. Gross Basic Rent 30. Gross Note Rate Rent

a. Basic Rent $ a . Note Rate Rent

b. Utility Allowance $ b. Utility Allowance C. (Line 29.a. + Line 29.b.) $ c. (Line 30.a. + Line 30.b)

PART VII DETERMINING GROSS TENANT CONTRIBUTION (GTC)

Decision: (check- one) A. If tenant receives rental assistance (RA) enter Line 28 on Line 31 below. If Line 28 exceeds Line 29..c., go to Decision B since this Tenant will not receive RA..

B. If tenant does not receive RA and this project receives Plan II Interest Credit, enter the greater of Line 28 or Line 29..c. (but not to exceed Line 30.c.) on Line 31 below.

C. If tenant does not receive RA and this project is a Plan I, Full Profit or Labor Housing project complete Lines C.1. thru C.3. and enter Line C.3. on Line 31.

$C.1. Enter Line 30.c.

C.2. Add Plan I Surcharge (if any) $ C.3. Total (enter on Line 31) $

PART IX-DETERMINING NET TENANT CONTRIBUTION (NTC)

31. GTC (From PART VIII) 32.. Utility Allowance (Line 29.b. or Line 30.b.)

33. Final N'TC (Line 31 minus Line 32)

(Amount Tenant pays Borrower for rent. If Line 33 is negative, Borrower pays the difference to Tenant for utilities.)

PART X - CERTIFICATION BY BORROWER

I certify that the information on this form has been verified as required by federal law and the tenant household is eligible to live in the unit, or has been granted ineligible occupancy by RHS.

a. Date Signed b. Signature of Borrower or Borrower's Representative

MM DD YY

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