Housing (PH & HCV): Income Verification Acknowledgement

The Housing Authorities of Dickson and Waverly
Monday - Friday 7:30 a.m. - 4:30 p.m.
dicksonhousing.org

Dickson Housing
Waverly Housing

Administrative Offices
615-446-9371
333 Martin Luther King Jr. Blvd
Dickson, TN 37055

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

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

By signing below, I understand that:

1. I must report all changes in my income and changes of the income from persons living in my household within ten (10) days as specified in the Housing Authority of Dickson and Waverly Dwelling Lease and related documents.
   
   
2. The Housing Authorities of Dickson and Waverly use 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 Housing Authorities of Dickson and Waverly to make inquiries regarding my income as necessary.
   
   
3. If the Housing Authorities of Dickson and Waverly becomes aware of income that I have not reported, or under-reported income, as specified in the Housing Authorities of Dickson and Waverly'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 Housing Authorities of Dickson and Waverly 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.