Instructions: Read through each section, include additional contact information (optional), and sign and date this form. 
Participant Name:      

Eligibility 	
I am eligible to continue to receive Bridges Program rental assistance as long as all of the following conditions are met: 
•	Thirty percent (30%) of my household gross monthly income is less than the full rent for my rental unit
•	I report all required household composition and income changes
•	The Minnesota Legislature continues to appropriate funds for the Bridges Program 

Ineligibility	

I understand that if I do any of the following, I may become ineligible for the rental assistance:
•	Refuse to apply for the Section 8 Housing Choice Voucher Program when the waiting list becomes open for applications
•	Refuse to accept a Section 8 Housing Choice Voucher when my name comes to the top of the list
•	Do not use a Section 8 Housing Choice Voucher that is issued to me
•	Do not provide required documentation and access to my rental unit to complete the annual recertification process in a timely manner (income information and housing inspection) 
•	Do not follow a recommended treatment plan after my behavior has placed me in danger of being evicted or has caused me to be evicted from my Bridges Program housing unit
•	Engage in illegal drug-related or violent criminal activity
•	Vacate my rental housing unit without giving proper notice to the landlord and the local Housing Agency, per the signed lease agreement
•	Commit fraud by not reporting all of my household’s income
•	Commit fraud by not reporting an additional adult in my household
•	Commit fraud by not reporting a decrease in household size 
If the Housing Agency determines that I am no longer eligible to participate in the Bridges Program, they will issue a notice of termination. I have 10 days to request a hearing to appeal the decision. In case the Housing Agency is unable to reach me regarding one of the items listed above, I authorize them to provide information to my additional contact listed below. NOTE: Providing additional contact information is optional. 

Additional Contact Information (optional)	
Name	     	Telephone	     	
Relationship	     	Email	     	

By signing below, I acknowledge the above terms are required for continued participation in the Bridges Program. 
                                                                                                                                                                  	
Signature of Participant 	Date