ATTACHMENT 3

APPLICANT/TENANT CERTIFICATION

APPLICANT/TENANT STATEMENT

I certify that this information* given to the Housing Authority of the Borough of Cliffside Park, 500 Gorge Road, Cliffside Park, New Jersey on household composition, household income, net family assets, and allowances and deductions is accurate and complete to the best of my knowledge and belief. I understand that false statements of information are punishable under Federal and State Law. I also understand that false statements or information are grounds for termination of housing assistance and termination of tenancy.

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

If you believe you have been discriminated against, you may call the Fair Housing and Equal Oppertunity National Toll-free Hot Line at 1-800-424-8590. (Within the Washington D.C. Metropolitan Area call 426-3500.)

*After verification by this Housing Agency, the information will be submitted to the Department of Housing and Urban Development on Form HUD50058. (Tenant Data Summary), a computer-generated facsimile of the form. See the Federal Privacy Act Statement for more information about its use.