Name*
Full Name
Email* Address*
Emergency Contact Name
Full Name
Emergency Contact Address
The Household
The head of household is:* All other adult household members must sign below. Excluding yourself, how many adults (ages 18+) are in your household?* Signee #2 - Spouse or Additional Adult* Signee #2 Full Name*
Full Name
Signee #2 Email Address* I describe my household as:* AND:* I best understand, and prefer to communicate in:* My household includes someone who:* Do you need assistance to complete the forms required to determine your eligibility?* Will you have any anticipated changes in your household?* Anticipated household changes:* Click the plus sign to add more rows.
Enter People 18 Years of Age or Older Below (Adults) - SEE codes above* Please list the Head of Household first, then list all other adults. Click the plus sign to add more rows.
Are there people UNDER the age of 18 that you need to list?* Enter people UNDER 18 Years of Age Below (Minors) – SEE codes above* Click the plus sign to add more rows.
Is there a parent of a minor NOT in the home?* If the parent of a minor is NOT in the home, provide the information below:* Click the plus sign to add more rows.
Head of Household Income/Grants* Do you have any additional Income/Grants to list? (Head of Household)* Other Income/Grants (Head of Household)* Please list any other income/grants including: Foster Care/Adopt Assistance, Child Support Income, Rental Income/Property, Self Employed/Own Business, Financial Aide, Stock Dividends, Recycling, Gifts/Contributions/Support.
Provide contact information for the income sources identified above with an * (Wages/Salary and Alimony)
Do you have Income/Grants that you need to report for Other Household Members?* Other Household Members' Income/Grants* Other Income/Grants* For each individual you listed above, please also list any other income/grants including: Foster Care/Adopt Assistance, Child Support Income, Rental Income/Property, Self Employed/Own Business, Financial Aide, Stock Dividends, Recycling, Gifts/Contributions/Support.
Provide contact information for the income sources identified above with an * (Wages/Salary and Alimony)* Does anyone outside your household pay for or provide money for any of your household bills or living expenses?*
Do you have any Full-Time Students/Self-Sufficiency to Report?* Full-Time Students/Self Sufficiency*
Does anyone in the household own alone, or with others, any property or land?* Does anyone in the household have a Trust?* Does anyone in the household have an insurance policy with “cash” value you can withdraw?* Do you or anyone in the household have an account with a bank or credit union?* List accounts for any and all banks or credit unions.* Please list all accounts associated with each household member. Click the plus sign to add another row.
Does any household member have a “pre-paid” debit-card for monthly benefits?* List accounts for any and all "pre-paid" debit cards.* Please list all accounts associated with each household member. Click the plus sign to add another row.
Does anyone in your household own a car?* List Cars* List all cars owned by members of the household, or registered to your address. Click the plus sign to add another row.
Do you have any Childcare Expenses to Report?* Childcare Expenses* List care for children 13 years (or younger) – to allow someone to work or attend school. Click the plus sign to add another row. Note: If you don’t have proof of childcare expense, your Recertification will be processed without the deduction. It can be revised later, when proper evidence of payments is received, but will not be retroactive.
Do you want to apply for a medical deduction?* If yes, please attach evidence when prompted. Note: If you don’t have proof of medical expense, your Recertification will be processed without the deduction. It can be revised later, when proper evidence of payments is received, but will not be retroactive.
List All Expenses (Prescriptions, Dr Co-Pay, Health Plan/Insurance, Attendants/Aides, Transportation, Prescribed Over-the-Counter)* Click the plus sign to add another row.
2. Are you living in a unit that is owned by a relative?* Check here if none:* 6. In the past year, have you, or any member of your household had any involvement with law enforcement including, not limited to an arrest, conviction, parole or probation?* 7. Is anyone in the household on parole?* 8. Is anyone in the household on probation?* 9. Is anyone in the household required to register as a sex offender?* 10. Is anyone in the household in treatment for alcohol or drug abuse/addiction?* 11. Are you, or any member in your household receiving rental assistance from another Housing Authority or below-market rent program?* 12. Do you have a live-in aid?* 12a. My live-in aid IS or IS NOT living in the unit on a full-time basis:* (Only required to answer if approved for a Reasonable Accommodation)
13. Have you been approved for a Reasonable Accomodation?* 13a. I am using the extra bedroom:* (Only required to answer if approved for a Reasonable Accommodation)
Certification* Legal Consent* Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures
I agree to the terms and conditions.
PHA or IHA requesting release of information:
Original is retained by the requesting organization.HUD-9886-A (10/23) exp. 10/31/26
Purpose: In signing this consent form, you are authorizing HUD and the above-named HA to request income information from the sources listed on the form. HUD and the HA need this information to verify your household’s income, in order to ensure that you are eligible for assisted housing benefits and that these benefits are set at the correct level. HUD and the HA may participate in computer matching programs with these sources in order to verify your eligibility and level of benefits.
Uses of Information to be Obtained: HUD is required to protect the income information it obtains in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. HUD may disclose information (other than tax return information) for certain routine uses, such as to other government agencies for law enforcement purposes, to Federal agencies for employment suitability purposes and to HAs for the purpose of determining housing assistance. The HA is also required to protect the income information it obtains in accordance with any applicable State privacy law. HUD and HA employees may be subject to penalties for unauthorized disclosures or improper uses of the income information that is obtained based on the consent form. Private owners may not request or receive information authorized by this form.
Failure to Sign Consent Form: Your failure to sign the consent form may result in the denial of eligibility or termination of assisted housing benefits, or both. Denial of eligibility or termination of benefits is subject to the HA’s grievance procedures and Section 8 informal hearing procedures.
Revocation of Consent: If you revoke consent, the PHA will be unable to verify your information, although the data matches between HUD and other agencies will continue to automatically occur in the Enterprise Income Verification (EIV) System if the family is not terminated from the program.
Consent* I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form for the purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs that receive income information under this consent form cannot use it to deny, reduce or terminate assistance without first independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In addition, I must be given an opportunity to contest those determinations.
This consent form remains effective until the earliest of (i) the rendering of a final adverse decision for an assistance applicant; (ii) the cessation of a participant’s eligibility for assistance from HUD and the PHA; or (iii) The express revocation by the assistance applicant or recipient (or applicable family member) of the authorization, in a written notification to HUD or the PHA.
I agree to the terms above.
Privacy Advisory: Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair Housing Act (42 U.S.C. 3601-19). Purpose: This form authorizes HUD and the above-named HA to request income information to verify your household’s income in order to ensure that you are eligible for assisted housing benefits and that these benefits are set at the correct level. Failure to provide any of the requested information may result in a delay or rejection of your eligibility approval.
Penalties for Misusing this Consent: HUD and the HA (or any employee of HUD or the HA) 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 the form HUD 9886 is restricted to the purposes cited on the form HUD 9886. Any person who knowingly or willfully 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 HA for the unauthorized disclosure or improper use.
OMB Burden Statement: The public reporting burden for this information collection is estimated to be 0.16 hours for new admissions and .08 hours for household members turning 19, including the time for reviewing, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Collection of information income and assets is required for program eligibility determination purposes. The submission of the consent form is necessary (form-HUD 9886) so that PHAs can carry out the requirements of Section 904 of the Stewart B. McKinney Homeless Assistance Amendments Act of 1988, as amended by Section 903 of the Housing and Community Development Act of 1992 and Section 3003 of the Omnibus Budget Reconciliation Act of 1993 (42 U.S.C. 3544) and Section 104 of HOTMA to ensure that HUD and PHAs can verify eligibility and income information for applicants and participants. This information collection is protected from disclosure by the Privacy Act. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions to reduce this burden, to the Office of Public and Indian Housing, US. Department of Housing and Urban Development, Washington, DC 20410. When providing comments, please refer to OMB Approval No. 2577-0295. HUD may not conduct and sponsor, and a person is not required to respond to, a collection of information unless the collection displays a valid control number.
