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SECTION 3 INDIVIDUAL LOW-INCOME PERSON SELF-CERTIFICATION FORM
(In compliance with Section 3 of the HUD Act of 1968)
The purpose of this form is to comply with Section 3 of the HUD Act of 1968 self-certification
income requirements.To count as a Section 3 individual, any legal resident of the United States
annual income must not exceed the HUD income limits for the year before they were hired, or,
the individual's current year annualized for the year you are being confirmed as low-income.
Printed Name:
Street Address: (No P.O. Box) Apt# City State Zip
Phone#: Email:
To qualify as a Section 3 person, you must meet one of the categories below.
Check only one line below that describes your situation:
_ Iam a Public Housing Resident or Section 8 assists me with my rent.
_ 1 was a Public Housing Resident or Section 8 assisted me with my rent. If so what year and where did you reside:
_I receive no HUD support, but 1 am low-income because my individual income does not exceed $59,650
and I live in the Hampton Roads Metropolitan area.
_ Are you currently or have you ever been a YouthBuild participant; if so when and where:
For additional comments:
Thereby certify to the US Department of Housing and Urban Development (HUD)
that all of the information on this form is true and correct. I attest under penalty of
perjury that my total income does not exceed the income shown above, and that
proof of this information may be requested. I understand if found inaccurate, I may
be disqualified as an applicant and/or a certified Section 3 individual. Finally, I
authorize including my name on a list of Section 3 residents seeking employment
and to include my contact information so that contractors may contact me directly
for any employment opportunities.
Signature: Date:
Financial Operations, IC & RA Review Initial:
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