Updated 12/14

Voluntary Race, Ethnicity & Disability Data Reporting Form

Nebraska Investment Finance Authority (NIFA) requests this information in order to comply with Housing and Economic Recovery Act of 2008 which requires annual reporting of certain information to the United States Department of Housing and Urban Development. Although NIFA would appreciate receiving this information, you may choose not to provide it. You will not be discriminated against on the basis of this information, or on whether or not you choose to provide it. If you do not wish to provide this information, please check the box and initial below. Resident/Applicant: I do not wish to furnish information regarding race, ethnicity and disability. (Initials)________ See reverse side for Race, Ethnicity & Disability definitions. Enter both Ethnicity and Race codes for each household member. ____________________________________________________ ____________________________________________ Name of Property Property Address ________________________________________________________________________ ___________________ Name of Owner/Managing Agent Unit # *More than one race may be checked for each household member

Last Name First Name Race

:

Amer

ican

Indi

an o

r Ala

ska

Nat

ive

Asia

n

Blac

k or

Afr

ican

Am

eric

an

Nat

ive

Haw

aiia

n or

Oth

er

Paci

fic Is

land

er

Whi

te

Ethn

icity

:

Hisp

anic

or L

atin

o

Not

-Hisp

anic

or L

atin

o

Disabled? Y/N

1

2

3

4

5

6

7

8 _________________________________________________ _____________________________________________

Signature Date

Updated 12/14

Definitions: Racial Categories

• American Indian or Alaska Native – A person having origins in any of the original peoples of North and South American (including Central American), and who maintains tribal affiliation or community attachment.

• Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian

subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

• Black or African American – A person having origins in any of the black racial groups of Africa. Terms such as

“Haitian” or “Negro” can be used in addition to “Black” or “African American”.

• Native Hawaiian or other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

• White – A person having origins in any of the original peoples of Europe, the Middle East or North Africa.

Ethnicity Categories

• Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race. The term “Spanish origin” can be used in addition to “Hispanic” or “Latino”.

• Not Hispanic or Latino – A person not of Cuban, Mexican, Puerto Rican, South or Central American or other

Spanish culture or origin, regardless of race. Disabled?

• Enter Yes if any member of the household is disabled according to Fair Housing Act definition for handicap (disability):

• A physical or mental impairment which substantially limits one or more major life activities; a record of such impairment; or being regarded as having such an impairment. For a definition of "physical or mental impairment" and other term used in this defination, please see 24 CFR 100.201, available at http://www.fairhousing.com/index.cfm?method=page.display&pagename=regs_fhr_200-201.

• "Handicap" does not include current, illegal use of or addition to a controlled substance. • An individual shall not be considered to have a handicap solely because that individual is a transvestite.

• The housing credit agency administering its low-income housing credit program must, to the best of its ability, provide this disability status information, pursuant to 42 U.S.C. 1437z-8. However, it is the tenant's voluntary choice whether to provide such information and questions to the tenant requesting the information must so state. If the tenant declines to provide the information, the housing credit agency shall use its best efforts to provide the information, such as by noting the appearance of a physical disability that is readily apparent and obvious, or by relying on a past year's information. For purposes of gathering this information, no questions with respect to the nature or severity of the disability are appropriate.

• Enter No if no member of the household is disabled

ANNUAL STUDENT CERTIFICATION

Effective Date: _____________________ Move-in Date: _____________________ (MM/DD/YYYY)

(Updated 12/14)

This Annual Student Certification is being delivered in connection with the undersigned's application/occupancy in the following apartment:

Head of Household Name: Unit Number:

BIN:

Check A, B, or C, as applicable (note that “student” includes those attending public or private elementary schools, middle or junior high schools, senior high schools, colleges universities, technical, trade, or mechanical schools, but does not include those attending on-the-job training courses): A. _____ Household contains at least one occupant who is not a student and has not been/will not be a

student for five or more months out of the current and/or upcoming calendar year (months need not be consecutive). If this item is checked, no further information is needed. Sign and date below.

B. _____ Household contains all students, but is qualified because the following occupant(s)

___________________________________ is/are a PART TIME student(s). Verification of part time student status is required for at least one occupant.

C. _____ Household contains all FULL TIME students for five or more months out of the current and/or

upcoming calendar year (months need not be consecutive). If this item is checked, questions 1-5, below must be completed:

1. Are the students married and entitled to file a joint tax return? (attach marriage certificate

or tax return) YES NO

2. Is at least one student a single parent with child(ren) and this parent is not a dependent of another individual and the child(ren) is/are not dependent(s) of someone other than a parent? (attach student’s most recent tax return or Certification of Dependent Child(ren))

YES NO

3. Is at least one student receiving Temporary Assistance to Needy Families (TANF), formally known as Aid to Families with Dependant Children (AFDC) (provide third party verification)

YES NO

4. Does at least one student participate in a program receiving assistance under the Job Training Partnership Act, Workforce Investment Act, or under other similar, federal, state or local laws? (attach verification of participation)

YES NO

5. Does the household consist of at least one student who was previously under foster care? (Provide verification of participation)

YES NO

Full-time student households that are income eligible and satisfy one or more of the above conditions are considered eligible. If questions 1-5 are marked NO, or verification does not support the exception indicated, the household is

considered an ineligible student household.

Under penalty of perjury, I/we certify that the information presented in this certification is true and accurate to the best of my knowledge. The undersigned further understand(s) that providing false representation herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination of a lease agreement.

All household members age 18 or older must sign and date.

Signature (Date) Signature (Date) Signature (Date) Signature (Date)

UNEMPLOYED AFFIDAVIT

This Affidavit is to be signed by each individual 18 years of age and older when no employment income for them is indicated on the Tenant Income Certification.

Check applicable statement:

I am not presently employed and do not anticipate becoming employed within the next twelve (12) months.

I am not presently employed, and not aware of an employment start date, but

anticipate becoming employed within the next twelve (12) months. Based on my past work experience, skills, and income history, I expect to earn $ /year when I become employed.

I am not presently employed, but am aware of an employment start date

of at $ per (If amount is hourly, please provide

number of hours per week, ).

Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. The undersigned further understands that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination of a lease agreement. ________________________________ ____________________________ __________________ Signature of Applicant/Tenant Printed Name Date (Updated 12/14)

EMPLOYMENT VERIFICATION

TO:

RE: Applicant/Tenant Name Social Security Number Unit # (if assigned) I hereby authorize release of my employment information. ________________________________________ ____________________________________ Signature of Applicant/Tenant Date The individual named directly above is an applicant/tenant of a housing program that requires verification of income. The information provided will remain confidential and will be used solely for the purpose of determining eligibility for occupancy. Your prompt response is crucial and greatly appreciated.

________________________________________ Signature of Owner’s Representative

Return Form To:

Employer [company] Name & Address Phone Number Fax Number

Excel Development Group 8551 Lexington Ave, Lincoln, NE 68505 Phone: 800-378-9366 Fax: 402-434-3343

*PLEASE COMPLETE EVERY LINE – IF IT DOES NOT APPLY PLEASE WRITE N/A OR NONE*

Employee Name: Job Title:

Presently Employed: Yes Date First Employed No Last Day of Employment

Current Wages/Salary: $ per (circle only one) hourly weekly bi-weekly semi-monthly monthly yearly other

Frequency of Pay: (circle only one) daily weekly bi-weekly semi-monthly monthly yearly other _____________

Ave # of regular hours per wk: Year-to-date gross earnings: $ From / / through / / Number of pay periods included in the YTD earnings above:____________________

Overtime Rate: $ per hour Average # of overtime hours per week:

Shift Differential Rate: $ per hour Average # of shift differential hours per week:

Commissions, bonuses, tips, other: $ (circle only one) hourly weekly bi-weekly semi-monthly monthly yearly other

List any anticipated change in the employee’s rate of pay within the next 12 months: ; Effective date:

If the employee’s work is seasonal or sporadic, please indicate the layoff period(s):

Does the employee participate in a 401K/Retirement account? Yes No Employee can access the account? Yes No

Additional remarks:

Employer’s Signature

Employer’s Printed Name

Date

Employer [Company] Name and Address

Phone #

Fax #

E-mail

NOTE: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the United States as to any matter within its jurisdiction. (Updated 12/14)

THIS SECTION TO BE COMPLETED BY TENANT AND EXECUTED BY MANAGEMENT

THIS SECTION TO BE COMPLETED BY EMPLOYER