HUD 90102 Sample Verification of Disability

VERIFICATION OF DISABILITY

U.S. Department of Housing and Urban Development Office of Housing Federal Housing Commissioner

OMB Control No. 2502–0204 (exp. xx/xx/xxxx)

SAMPLE VERIFICATION OF DISABILITY WHEN ELIGIBILITY FOR ADMISSION TO CERTAIN MULTIFAMILY PROGRAMS OR ELIGIBILITY FOR CERTAIN INCOME DEDUCTIONS IS BASED ON DISABILITY

Public Reporting Burden. The public reporting burden for this collection of information is estimated to average 5 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. Comments regarding the accuracy of this burden estimate and any suggestions for reducing this burden can be sent to U.S. Department of Housing and Urban Development, Office of the Chief Data Officer, 451 7th St SW, Room 8210, Washington, DC 20410–5000. Do not send completed forms to this address. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the collection displays a valid OMB control number. Owners/management agents must obtain third-party verification that a disabled individual meets the definition of a person with disabilities for the program governing the housing where the individual is applying to live. For the purpose of verifying eligibility, the applicable definition for persons with disabilities for the Section 202 PAC and 202/8 programs is found at 12 USC 1701q(d)(4) as it existed before the Cranston-Gonzalez National Affordable Housing Act of 1990 and 24 CFR 891.505 (“handicapped person or individual”) and for Section 811 PRAC is found at 42 USC 8013(k)(2) and 24 CFR 891.305. For the purpose of verifying eligibility for admission under an owner-adopted elderly preference established pursuant to Section 651 of Title VI, Subtitle D of the Housing and Community Development Act of 1992, the applicable definition for persons with disabilities is found at 42 USC 1437(a)(b)(3) and 24 CFR 5.403. For the purpose of income calculations, the applicable definition for person with disabilities is found at 24 CFR 5.403. HUD collects this information to comply with the United States Housing Act of 1937. HUD uses the information to verify an applicant’s disability. Providing this information is voluntary. Failure by the owner/agent to verify an individual’s disability may impact an applicant’s eligibility for admission or a tenant’s qualification for certain income deductions based on disability.

Privacy Act Statement: The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937, as amended (42 U.S.C. 1437 et. seq.); the Housing and Urban-Rural Recovery Act of 1983 (P.L.98-181); the Housing and Community Development Technical Amendments of 1984 (P.L. 98-479); and by the Housing and Community Development Act of 1987 (42 U.S.C. 3543). The data compiled is reported on the HUD 50059. The information provided will not be disclosed outside of the agency and used solely for internal statistical compliance purposes, except as required by law or as permitted by the following System of Records Notice: HSNG/MF.HTS.02, Tenant Rental Assistance Certification System (TRACS)—HUD/HOU–11, published in the Federal Register on September 12, 2023, 81-FR-56684. https://www.federalregister.gov/documents/2023/09/13/2023-19782/privacy-act-of-1974-system-of-records.

DATE: ______________________________

TO:		FROM:
	(Name and address of third party who is being requested to verify this information)		(Name of individual requesting the information, title, name of the housing project, address)

SUBJECT: Verification of Disability for HUD Housing Programs

Name of Applicant/Tenant
Name of Head of Household (if different)
Address of Applicant/Tenant

Instructions for Third Party: The applicant/tenant named above has applied for housing assistance or claims eligibility for an income deduction under a program administered by the U.S. Department of Housing and Urban Development (HUD). HUD requires the housing provider to verify all information that is used in determining eligibility for certain programs or level of benefits, including disability status.

This form is divided into three parts. Part I verifies disability for eligibility for admission into HUD’s 202 PAC, 202/8, and 811 PRAC programs. Part II verifies an applicant’s disability for eligibility for an owner-adopted elderly preference under Section 651 of Title VI, Subtitle D of the Housing and Community Development Act of 1992. Part III verifies disability for eligibility purposes for certain income deductions for all HUD’s Multifamily rental assistance programs. Part IV is the applicant/tenant’s consent to release the information. Complete only Parts I, II, or III as indicated below with a check mark.

We ask for your cooperation in providing the following information, signing/dating the form, and returning all pages to the person listed at the top of this form. Your prompt return of this information will help to ensure timely processing of the individual’s application for assistance. Enclosed is a self-addressed, stamped envelope for this purpose.

Part I: INFORMATION REQUESTED TO VERIFY ELIGIBLITY FOR ADMISSION BASED ON DISABILITY into THE 202 PAC, 202/8, and 811 PRAC PROGRAMs

1. Does the applicant meet at least one of the below criteria (A–C)?

☐YES ☐ NO

1. Has a physical, mental, or emotional impairment that is expected to be of long-continued and indefinite duration, substantially impedes his or her ability to live independently, and is of a nature that such ability could be improved by more suitable housing conditions.

2. Has a developmental disability, as defined in Section 102(7) of the Developmental Disabilities Assistance and Bill of Rights Act (42 U.S.C. 15002) (i.e., is a person with a severe chronic disability) that:

1. Is attributable to a mental or physical impairment or combination of mental and physical impairments;

2. Is manifested before the person attains age 22;

3. Is likely to continue indefinitely;

4. Results in substantial functional limitation in three or more of the following areas of life: (a) Self-care, (b) Receptive and expressive language, (c) Learning, (d) Mobility, (e) Self-direction, (f) Capacity for independent living, and (g) Economic self-sufficiency; and

5. Reflects the person’s need for a combination and sequence of special, interdisciplinary, or generic care, supports, treatment, or other services that are of lifelong or extended duration and are individually planned and coordinated.

3. Has a chronic mental illness (i.e., he or she has a severe and persistent mental or emotional impairment that seriously limits his or her ability to live independently) and his/her impairment could be improved by more suitable housing conditions.

2. Is the applicant/tenant’s sole impairment a drug or alcohol addiction?

☐YES ☐ NO

I/We, the undersigned, certify under penalty of perjury that the information provided above is true, correct, and accurate. WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012, 1014; 31 U.S.C. §3729, 3802).

Name and title of person supplying the information ____________________________________

Firm/Organization supplying the information _________________________________________

Signature ____________________________________ Date______________________________

Part II: INFORMATION REQUESTED TO VERIFY disability for ELIGIBLITY FOR owner-adopted preference under Section 651 of Title VI, Subtitle D of the Housing and community Development act of 1992

Part II applies only to the following Section 8 programs: New Construction, Substantial Rehabilitation, State Housing Agency programs for Section 8 New Construction and Substantial Rehabilitation, Rural Housing 515/8, and Property Disposition Set-Aside.

1. Does the applicant meet at least one of the below criteria (A–C)?

☐ YES ☐ NO

1. Has a physical, mental, or emotional impairment that is expected to be of long-continued and indefinite duration, substantially impedes his or her ability to live independently, and is of a nature that such ability could be improved by more suitable housing conditions.

2. Has a developmental disability as defined in Section 102(7) of the Developmental Disabilities Assistance and Bill of Rights Act (42 U.S.C. 15002) (i.e., a person with a severe chronic disability) that:

1. Is attributable to a mental or physical impairment or combination of mental and physical impairments;

2. Is manifested before the person attains age 22;

3. Is likely to continue indefinitely;

4. Results in substantial functional limitation in three or more of the following areas of major life activity: (a) Self-care, (b) Receptive and expressive language, (c) Learning, (d) Mobility, (e) Self-direction, (f) Capacity for independent living, and (g) Economic self-sufficiency;

5. Reflects the person's need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration and are individually planned and coordinated; and

6. Is an individual from birth to age 9, inclusive, who has a substantial developmental delay or specific congenital or acquired condition, may be considered to have a developmental disability without meeting 3 or more of the criteria described in clauses (a) through (e) of subparagraph iv. if the individual, without services and supports, has a high probability of meeting those criteria later in life.

3. Has a disability, as defined in 42 U.S.C. 423, which means:

1. Inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months; or

2. In the case of an individual who has attained the age of 55 and is blind, inability by reason of such blindness to engage in substantial gainful activity requiring skills or abilities comparable to those of any gainful activity in which he/she has previously engaged with some regularity and over a substantial period of time. For the purposes of this definition, the term blindness, as defined in section 416(i)(1) of the title, means central vision acuity of 20/200 or less in the better eye with use of a correcting lens. An eye which is accompanied by a limitation in the fields of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees shall be considered for the purposes of this paragraph as having a central visual acuity of 20/200 or less.

2. Is the applicant/tenant’s sole impairment a drug or alcohol addiction?

☐YES ☐ NO

I/We, the undersigned, certify under penalty of perjury that the information provided above is true, correct, and accurate. WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012, 1014; 31 U.S.C. §3729, 3802).

Name and title of person supplying the information

Firm/Organization supplying the information

Signature______________________________ Date

Part III: INFORMATION REQUESTED TO VERIFY ELIGIBLITY of tenants FOR CERTAIN INCOME DEDUCTIONS FOR ALL MULTIFAMILY RENTAL ASSISTANCE PROGRAMS

1. Does the tenant meet at least one of the below criteria (A–C)?

☐ YES ☐ NO

1. Has a physical, mental, or emotional impairment, of which the impairment is not solely a drug or alcohol addiction, that is expected to be of long-continued and indefinite duration, substantially impedes his or her ability to live independently, and is of a nature that such ability could be improved by more suitable housing conditions.

2. Has a developmental disability as defined in Section 102(7) of the Developmental Disabilities Assistance and Bill of Rights Act (42 U.S.C. 15002) (i.e., a person with a severe chronic disability) that:

1. Is attributable to a mental or physical impairment or combination of mental and physical impairments;

2. Is manifested before the person attains age 22;

3. Is likely to continue indefinitely;

4. Results in substantial functional limitation in three or more of the following areas of major life activity: (a) Self-care, (b) Receptive and expressive language, (c) Learning, (d) Mobility, (e) Self-direction, (f) Capacity for independent living, and (g) Economic self-sufficiency;

5. Reflects the person's need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration and are individually planned and coordinated; and

6. Is an individual from birth to age 9, inclusive, who has a substantial developmental delay or specific congenital or acquired condition, may be considered to have a developmental disability without meeting 3 or more of the criteria described in clauses (a) through (e) of subparagraph iv. if the individual, without services and supports, has a high probability of meeting those criteria later in life.

3. Has a disability, as defined in 42 U.S.C. 423, which means:

1. Inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months; or

2. In the case of an individual who has attained the age of 55 and is blind, inability by reason of such blindness to engage in substantial gainful activity requiring skills or abilities comparable to those of any gainful activity in which he/she has previously engaged with some regularity and over a substantial period of time. For the purposes of this definition, the term blindness, as defined in section 416(i)(1) of the title, means central vision acuity of 20/200 or less in the better eye with use of a correcting lens. An eye which is accompanied by a limitation in the fields of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees shall be considered for the purposes of this paragraph as having a central visual acuity of 20/200 or less.

I/We, the undersigned, certify under penalty of perjury that the information provided above is true, correct, and accurate. WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012, 1014; 31 U.S.C. §3729, 3802).

Name and title of person supplying the information

Firm/Organization supplying the information

Signature______________________________ Date

Part IV: APPLICANT/TENANT CONSENT FOR THE RELEASE OF INFORMATION

Note to Applicant/Tenant: You do not have to sign this form if either the requesting organization or the name/title of the person requested to supply the information is left blank.

RELEASE: I hereby authorize this information to be released to the individual requesting the information. Information obtained under this consent is limited to information that is no older than 12 months.

Print Name

Signature

Date

PENALTIES FOR MISUSING THIS CONSENT

HUD and any owner (or any employee of HUD 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 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 damages and seek other relief, as may be appropriate, against the officer or employee of HUD 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). Violations of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).

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HUD form–90102