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Eligibility Status Ethnicity & Race of Head of Household <br /> O Income Eligible < 80% Circle One <br /> 11 — White <br /> Security Deposit Paid : $ 12 — Black or African American <br /> 13 — Hispanic <br /> BY : ❑ Tenant ❑ PHA 14 — Asian <br /> 15 — American Indian or Alaska Native <br /> Utility Deposit Paid : $ 16 — Native Hawaiian or Other Pacific Islander <br /> 17 — American Indian or Alaska Native & White <br /> BY : ❑ Tenant ❑ PHA 18 — Asian & White <br /> 19 — Black or African American & White <br /> Pro-rated Rent Paid : $ 20 — American Indian or Alaska Native & Black or African American <br /> 21 — Other Multi Racial <br /> BY : ❑ Tenant ❑ PHA <br /> RR <br /> Unit Rent Information <br /> a . Tenant Paid Rent: b . Move -in Date <br /> c . Housing Assistance Payment : d. Current rent limit (FMR) $ <br /> e . Total Landlord Rent <br /> Unit Meets Rent Restriction at ❑ 30 % ❑ Written verification of <br /> income attached <br /> PHA CERTIFICATION <br /> I have verified the information presented on this form in accordance with the requirements of the Program and the provisions of any applicable <br /> deed <br /> restrictions . I possess the documentation necessary to support this certification/recertification . To the best of my knowledge, the <br /> information <br /> presented on this form is complete and accurate . <br /> (Signature of Owner or Authorized Representative) (Date) <br /> (Printed Name) (Printed Title) <br /> For FHFC use only <br /> WARNING : Section 1001 of Title 18 of the U . S . Code makes it a criminal offense to willfully falsify a material fact or make <br /> a false statement in any matter <br /> within thejurisdiction of a federal agency. <br /> Florida Housing Finance Corporation Page 2 Attachment A, Exhibit 2 ( Rev . 09/05 ) <br />