Income Verification Acknowledgement

Haynesville Housing Authority
www.haynesvillehousing.org
Office: 318.624.1272
1953 Mill Street • PO Box 751 • Haynesville, LA 71038
Monday - Thursday 8:00 am - 6:00 pm

Fields marked with * must be completed or form will not submit.

All adults, 18 and over, are required to sign this acknowledgement.

By signing below, I understand that:

1. I must report all changes of my income and changes of the income from persons living in my household within ten (10) days as specified in the Haynesville Housing Authority Dwelling Lease and related documents.
   
   
2. The Haynesville Housing Authority uses electronic data matching, Upfront Income Verification (UIV), and other electronic and manual methods to verify reported income with independent sources. Types of electronic verification may include, but are not limited to, employment and other earnings, social security benefits, unemployment, etc. By signing this agreement, I hereby authorize the Haynesville Housing Authority to make inquiries regarding my income as necessary.
   
   
3. If the Haynesville Housing Authority becomes aware of income that I have not reported, or under reported income, as specified in the Haynesville Housing Authority's Dwelling Lease and related documents, I hereby acknowledge that I may be subject to certain penalties. These penalties may include, but not be limited to, repayment, current and future program ineligibility, and civil and/or criminal prosecution. 
   
   
4. If I am determined to be ineligible for housing assistance because: I did not comply with the relevant portions of the Dwelling Lease and related documents in timely reporting of income and therefore must repay the Haynesville Housing Authority under a properly executed Repayment Agreement, I hereby acknowledge that I may not be eligible for assistance from any other Housing Authority until I satisfy the offense by remitting the full amount listed in the Repayment Agreement in a timely manner. 
   
   
5. If I disagree with the findings, I hereby acknowledge that I have the right to request a review of the income and circumstances which caused the discrepancy with a member of management.