BRHP | Optional Contact Form

Optional Contact Form

You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form.

Applicant Name*
First Last
Applicant Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Applicant Home Phone Number
Applicant Cell Phone Number
Name of Additional Contact Person or Organization*
First Last
Contact Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Contact Phone Number*
Contact Email Address
Relationship to Applicant*
Reason for Contact (Check all that apply)*
- Emergency
- Unable to Contact You
- Termination of Rental Assistance
- Eviction from Unit
- Late Payment of Rent
- Assist with Re-certification Process
- Change in Lease Terms
- Change in House Rules
- Other
Commitment of the Housing Authority or Owner:
If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you.

Confidentiality Statement:
The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law.

Legal Notification:
Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992) requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of 1975.
Signature of Applicant*
Date*
Date Format: MM slash DD slash YYYY

Optional Contact Form

Optional Contact Form

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