BRHP | Employment Self-Certification

Employment Self-Certification

By completing and signing this form, you are certifying that you do not work at the company listed on this form. The Baltimore Regional Housing Partnership will check the information you provide on this form with other Federal, State, or local governments and with private agencies. Certifying false information is fraud. If you commit fraud to obtain assisted housing, you could be evicted from your apartment or house, required to repay all overpaid rental assistance you receive, fined up to $10,000, imprisoned for up to five years, prohibited from receiving future assistance, and/or subject to state and local government penalties.

Your Name*
First Last
Your Email*
Head of Household Name (If different from above)
First Last
Company Name*
Company Address*
Street Address Address Line 2 City State ZIP Code
Supervisor's Name
First Last
Supervisor's Email
Company Phone Number*
Company Fax Number
Last Date Employed*
MM slash DD slash YYYY
Signature*
I hereby certify under the penalty of perjury that the declarations I have made in this document are true and complete. I understand and acknowledge that any knowing or willful misrepresentations of the declarations (including submission of falsified supporting documentation to support my declarations) contained in this document may result in civil liability and/or criminal penalties, including but not limited to fine or imprisonment, or both under the provision of Title 18 of the United States Code (USC) Section 1001.
Date Signed*
MM slash DD slash YYYY

Employment Self-Certification

Employment Self-Certification

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