Print name(s) of household members signing this form	
     	     	
     	     	

Minnesota Housing is requesting that you supply information that relates to your application for rental assistance.

Some of the information you are being asked to provide to Minnesota Housing may be considered private or confidential under the Minnesota Government Data Practices Act, Minnesota Statutes chapter 13. Section 13.04(2) of that law requires that you be notified of the matters included in this Disclosure Statement before it is requested that you provide that information to Minnesota Housing. The rental assistance administrator and/or the owner of the property (Owner) may also ask you to supply information that relates to your application. The Owner’s request for information is not governed by the Minnesota Government Data Practices Act.

1.	Minnesota Housing is asking for information that is necessary for the administration and management of a state or federal program to provide housing for low- and moderate-income families. Some of the information may be used to establish your eligibility to initially occupy, or to continue to occupy, a unit in the property and/or to receive either state or federal rental assistance. Other information may be used to assist Minnesota Housing in the evaluation and management of some of the programs it operates.

2.	As part of your application, you are asked to supply the information contained in each of the following attachments that are checked with an “X” (all checked boxes apply). Each attachment has two parts: Part A and Part B.

 Attachment 1 – Bridges Rental Assistance Program
 Attachment 2 – Housing Trust Fund Rental Assistance Program
 Attachment 3 – Housing Opportunities for Persons with Aids (HOPWA) Program 
 
3.	Minnesota Housing may use the information requested under Part A of the checked attachment(s) to establish your eligibility to occupy a unit in the property or to receive state or federal rental assistance. If you refuse to supply any portion of the information asked for under Part A of the checked attachment(s), it may make you ineligible for initial or continued occupancy of a unit in the property or for receipt of state or federal rental assistance.

4.	The information requested under Part B of the checked attachment(s) will help Minnesota Housing in the evaluation and management of some of the programs it operates, and your supplying of this information will be very helpful to Minnesota Housing. Your failure to provide any of the information asked for under Part B of the checked attachment(s) will not affect whether or not you are eligible for initial or continued occupancy of a unit in the property or for state or federal rental assistance.  

5.	The Owner may also ask for information to determine whether or not he/she/they will rent you a unit in the property. Supplying, or refusal to supply, any information requested by the Owner will not affect a decision by Minnesota Housing, but your decision could affect the Owner’s decision as to whether he/she/they will rent a unit to you. The determination by the Owner is separate from Minnesota Housing’s determination, and Minnesota Housing does not participate, in any way, in the Owner’s decision.

6.	All of the information that you supply to Minnesota Housing will be accessible to Minnesota Housing staff and its contractors or agents for the purpose of managing and evaluating the program. The information may be made available to staff of the Office of the Minnesota Attorney General, the United States Department of Housing and Urban Development (HUD), the United States Internal Revenue Service (IRS), and other persons and/or governmental entities who have statutory authority to review the information, investigate specific conduct, and/or take appropriate legal action, including but not limited to law enforcement agencies, courts and other regulatory agencies. Minnesota Housing may also provide the information to the Owner’s management agents of the property. Minnesota Housing may provide the information to researchers for the purpose of evaluating the rental assistance programs or creating a better understanding of who is served by the program and the programs’ outcomes. Before receiving any data, the researchers must sign an agreement to protect your data in compliance with state government data practices law.

7.	This Disclosure Statement remains in effect for as long as you receive rental assistance under the program identified in #2, above.

I was (We were) supplied with a copy of and have read this Minnesota Housing Government Data Practices Act Disclosure Statement and the attachment(s) identified in #2, above.

Head of household, spouse, co-head and all household members age 18 or older must sign below:
	
Applicant/Tenant Signature			Date	     	
Applicant/Tenant Signature			Date	     	
Applicant/Tenant Signature			Date	     	
Applicant/Tenant Signature			Date	     	
Applicant/Tenant Signature			Date	     	

Attachment 1
Bridges Rental Assistance Program
Part A
1.	Household composition, legal name(s), age(s) and relationship to the head of household of all household members
2.	Diagnosed mental illness as defined in the Comprehensive Mental Health Act
3.	Verification that the head of household is eligible to receive a Section 8 Housing Choice Voucher subsidy or can definitely become eligible to receive a Section 8 Housing Choice Voucher subsidy based on successful participation in the Bridges Program (this rental assistance subsidy will only be provided if the person is on a waiting list or formally agrees to be on a waiting list when one is opened)
4.	Declaration of citizenship or legal non-citizenship of all household members
5.	Date of birth of all household members 
6.	Elderly, disabled or handicapped status of affected members of your household (for program eligibility and/or program allowances)
7.	Custody of minor children
8.	Non-immigrant student status
9.	Housing preferences by program or statute
10.	Employment or unemployment status
11.	Amount and source of all earned and unearned income of all household members
12.	Type, value and income derived from all household assets
13.	Type, value and income derived from all household assets disposed of for less than fair market value within the past two years
14.	Current and previous residency

Part B
1.	Race
2.	Ethnicity
3.	Gender of head of household
4.	Marital status 
5.	Occupation
6.	Need for reasonable accommodation for any member of the household
7.	Need for animal assistance and/or devices
8.	Disclosure of the use, sale, distribution or manufacture of illegal drugs of any adult household members
9.	Disclosure of arrests or convictions of the use or illegal distribution or manufacture of illegal drugs or controlled substances
10.	Disclosure of arrests or convictions of a felony or misdemeanor (other than a traffic violation)
11.	Disclosure of lifetime registration as a predatory sex offender of any adult household member
12.	Disclosure of a pattern of alcohol abuse of any adult household member that would interfere with other tenants’ rights
13.	Participation in self-sufficiency programs
14.	Disclosure of previous housing history
15.	PMI Number – Minnesota Health Care Program or Patient Master Index Number (PMIN)

Attachment 2
Housing Trust Fund Rental Assistance Program

Part A
1.	Household composition, legal name(s), age(s) and relationship to the head of household of all household members
2.	Declaration of citizenship or legal non-citizenship of all household members
3.	Non-immigrant student status
4.	Date of birth of household head
5.	Elderly, disabled or handicapped status of affected members of your household (for program eligibility and/or program allowances, if applicable)
6.	Custody of minor children
7.	Employment or unemployment status
8.	Amount and source of all earned and unearned income of all household members
9.	Type, value and income derived from all household assets
10.	Type, value and income derived from all household assets disposed of for less than fair market value within the past two years
11.	Current and previous residency
12.	Confirmation as to whether the applicant’s current and/or previous housing history meets the state’s definition of long-term homelessness (LTH) and/or households at significant risk of LTH

Part B
1.	Race			
2.	Ethnicity			
3.	Gender of head of household		
4.	Elderly, disabled or handicapped status of members of your household
5.	Marital status
6.	Need for reasonable accommodation for any member of the household
7.	Need for animal assistance and/or devices
8.	Disclosure of the use, sale, distribution or manufacture of illegal drugs of any adult household members
9.	Disclosure of arrests or convictions of the use or illegal distribution or manufacture of illegal drugs or controlled substances
10.	Disclosure of arrests or convictions of a felony or misdemeanor (other than a traffic violation)
11.	Disclosure of lifetime registration as a predatory sex offender of any adult household member
12.	Disclosure of a pattern of alcohol abuse of any adult household member that would interfere with other tenants’ rights
13.	Receipt of public assistance
14.	Housing preferences by program or statute
15.	Participation in self-sufficiency programs

Attachment 3
Housing Opportunities for Persons with Aids (HOPWA) Program

Part A
1.	Household composition, legal names(s), age(s) and relationship to the head of household of all household members
2.	Referral and confirmation of HIV status signed by authorized signatory/health care professional
3.	Amount and source of all earned and unearned income of all household members
4.	Amount, value and income derived from all household assets

Part B
1.	Race
2.	Ethnicity
3.	Gender of head of household
4.	Elderly, disabled or handicapped status of affected members of your household
5.	Need and verification of need for reasonable accommodation for any member of the household
6.	Need for assistive animal and/or devices
7.	Custody of children under the age of seven 
8.	Disclosure of children with elevated levels of lead in the blood (if residing in a property built prior to 1978)