NY Rising Housing Recovery Programs: UPDATE Housing Trust Fund Corporation NY Rising Housing Recovery Program HOUSEHOLD INCOME CERTIFICATION The undersigned certifies that: 1. My name is: . 2. My current mailing address is: ____________ (street number and name),(city), New York (state) (zip). 3. I am the owner of real property damaged by Hurricane Irene between August 26, 2011 and September 4, 2011, Tropical Storm Lee between September 7, 2011 and September 10, 2011, or Hurricane Sandy between October 27, 2012 and November 8, 2012 and said real property is located in:(city), County, New York at the street address (street number and name) and unit number_______________. 4.The number of people presently in my household who are 18 years of age or older is: 5.The number of people presently in my household who are younger than the age of 18 is: 6.The total number of people in my household is (line 4 + line 5) TOTAL: 7. I certify that, for the calendar year 2013, the total Adjusted Gross Income, from all sources, of my household, including my income, my spouse’s (if any) income, and the income of all other household members 18 years of age or older, before any deductions, $_______________. I further certify that the stated income is complete and correct. 8. I understand that my representations concerning my total household income are subject to audit. 9. I further understand and acknowledge that I will be required to provide documentation to verify that the income information I provide is true and accurate. I state that I have records fully supporting the representations I make concerning total household income and will provide those records to New York State personnel for inspection upon reasonable request during normal business hours. By executing this Certification, I acknowledge and understand that Title 18 United StatesCode Section 1001: (1) makes it a violation of federal law for a person to knowingly andwillfully (a) falsify, conceal, or cover up a material fact; (b) make any materially false,fictitious, or fraudulent statement or representation; or (c) make or use any false writing ordocument knowing it contains a materially false, fictitious, or fraudulent statement orentry, to any branch of the United States Government, and; (2) requires a fine,imprisonment for not more than five years, or both, for any violation of such Section.By executing this Certification, I acknowledge and understand that Section 189 of the New York State Finance Law: (1) makes it a violation of state law to knowingly present or cause to be presented to any employee, officer or agent of the State of New York (including any division or public benefit corporation) (a) a false or fraudulent claim for payment or approval; or (b) to use or cause to be made or use a false record or statement to get a false or fraudulent claim paid or approved by the State of New York. Persons who violate this Section may be liable for a civil penalty of not less than $6,000 and not more than $12,000, plus three times the amount of all damages, including consequential damages, sustained because of their action as well as costs incurred to recover any such penalties or damages. Form ZD06
Posted on: Tue, 08 Jul 2014 01:31:18 +0000
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