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  • LYNN LEAD ABATEMENT PROGRAM

    ~TENANT’S APPLICATION~

  • (1) TENANT APPLICANT #1 

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  • Format: (000) 000-0000.
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  • (2) TENANT APPLICANT #2 

    (Only mandatory if there is a second person applying)
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  • Format: (000) 000-0000.
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  • (3) Household Information

  • Rows

  • (4) Landlord

  • (5) Unit

  • Statistical Information

    The following information is required by our funding sources. Information will be kept completely confidential.

  • INCOME and ASSET DOCUMENTATION CHECKLIST:

    The following documentation applies to ALL persons who will reside in the household and must be included with your application to determine your income eligibility: 
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  • CERTIFICATION:

    I certify that, under penalty of perjury, all information on this application to the best of my/our knowledge is true.  I/We understand that false information given is sufficient grounds for rejection of this application.  Furthermore, verification may be obtained from any source herein.

  • LEAD PAINT HAZARDS IN ACCORDANCE WITH 24CFR35.

    I/We have been made aware of the hazards of lead that may affect the occupants of the property for which we reside. I/We understand that Lead Hazard Reduction Activities that employ Safe Work Practices may be required as part of the total rehabilitation project which the owner of this same property is seeking assistance. Further, I/we have been made aware of my/our disclosure, protection and re-location rights and responsibilities.

  • Penalty for False or Fraudulent Statement, U.S.C.

    "Title 18, Section 1001, provides:  "Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies...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 statements or entry, shall be fined not more than $10,000 or imprisoned not more than five (5 years) or both.

  • TENANT(S) MUST SIGN AND DATE APPLICATION

    *Incomplete applications will result in delay in processing
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  • ELIGIBILITY RELEASE FORM

  • Purpose: Your signature on this Eligibility Release Form, and the signatures of each member of your household who is 18 years of age or older, authorizes the Lynn Housing Authority & Neighborhood Development to obtain information from a third party relative to your eligibility in the:

    • HOME/CDBG Homebuyer Program
    • HOME/CDBG Rehabilitation Program(s)
    • DeLead Program

    Privacy Act Notice Statement: The Department of Housing and Urban Development (HUD) is requiring the collection of the information derived from this form to determine an applicant’s eligibility in a HOME/CDBG/DeLead Program(s) and the amount of assistance necessary using HOME/CDBG/DeLead funds.  This information will be used to establish level of benefit on the HOME/CDBG/DeLead program(s); to protect the Government’s financial interest; and to verify the accuracy of the information furnished.  It may be released to appropriate Federal, State, and local agencies when relevant, to civil, criminal, or regulatory investigators, and to prosecutors.  Failure to provide any information may result in a delay or rejection of your eligibility approval.  The Department is authorized to ask for this information by the National Affordable Housing Act of 1990.

    NOTE: THIS GENERAL CONSENT MAY NOT BE USED TO REQUEST A COPY OF A TAX RETURN.  IF A COPY OF A TAX RETURN IS NEEDED, IRS FORM 4506, “REQUEST FOR COPY OF TAX FORM” MUST BE PREPARED AND SIGNED SEPARATELY.

    Authorization: I authorize the Lynn Housing Authority & Neighborhood Development and HUD to obtain information about me and my household from the following sources that is pertinent to eligibility for participation in the HOME/CDBG/DeLead Program(s):

    • Any credit bureau, retail merchant’s association, bank, financial institution, or other credit-extending organization
    • Providers of alimony, child support, credit, handicapped assistance, pension/annuities, the U.S. Social Security Administration, the U.S. Department of Veteran’s Affairs, and Welfare agencies
    • All income information and employments records
    • Other (enter info below)

  • I understand that a photocopy of this form is as valid as the original.

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