Minnesota Housing Finance Agency
GOVERNMENT DATA PRACTICES ACT
DISCLOSURE STATEMENT

PRINT NAME(s) OF HOUSEHOLD MEMBER’SSIGNING THIS FORM 	

     	
     	

     	
     	

Minnesota Housing Finance Agency (“MHFA”) is asking you to supply information that relates to your application to occupy, or continue to occupy, a unit in the following property (“Property”):

     
     
     	

Some of the information you are being asked to provide to MHFA 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 you are asked to provide that information to MHFA.  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.	MHFA 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 MHFA 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):

	Attachment 1 - Section 8, 236, and 202 Programs		Attachment 4 - Deferred Loan (other than MARIF)	
	Attachment 2 - Housing Tax Credit Program		Attachment 5 - MARIF	
	Attachment 3 – ARM or LMIR First Mortgage 		Attachment 6 - HOME	

 Each Attachment has two parts: Part A and Part B.

3.	The information asked for under Part A of the checked Attachment(s) may be used by MHFA 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), you may not qualify for initial or continued occupancy of a unit in the Property or for receipt of State or Federal rental assistance.

4.	The information asked for under Part B of the checked Attachment(s) will help MHFA in the evaluation and management of some of the programs it operates and your supplying of this information will be very helpful to the MHFA.  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 qualify 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 it will rent a unit in the Property to you.  Your supplying of, or refusal to supply, any information requested by the Owner will not affect a decision by MHFA, but could affect the Owner’s decision of whether it will rent a unit to you.  The determination by the Owner is separate from MHFA’s determination and MHFA does not participate, in any way, in the Owner’s decision.

6.	All of the information that you supply to MHFA will be accessible to staff of the MHFA and may be made available to staff of the Office of the Minnesota Attorney General, the United States Department of Housing and Urban Development, the United States Internal Revenue Service, 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.  The information may also be provided by MHFA to the Owner’s management agents of the Property. Under certain circumstances the information that you supply to MHFA may become public data and available, upon written request, to the general public.

7.	This Disclosure Statement remains in effect for as long as you occupy a unit in the property and are a participant in the program(s) identified in #2, above.

I was (We were) supplied with a copy of and have read this Minnesota Housing Finance Agency 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	     	

Attachment 1
Section 8, 236 and 202 Programs
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.	Social Security Number disclosure of all household members, age 6 and older
4.	Date of birth of all household members 
5.	Elderly, disabled or handicapped status of affected members of your household (for program eligibility and/or program allowances)
6.	Custody of minor children
7.	Non-immigrant student status
8.	Housing preferences by program or statute
9.	Employment or unemployment status
10.	Amount and source of all earned and unearned income of all household members
11.	Type, value and income derived from all household assets
12.	Type, value and income derived from all household assets disposed of for less than fair market value within the past 2 years
13.	Participation in self-sufficiency programs
14.	Medical expenses (for program allowances)
15.	Handicap assistance expenses  (for program allowances)
16.	Child care expenses  (for program allowances)
17.	Need for reasonable accommodation for any member of the household
18.	Need for assistive animal and/or devices
19.	Credit and criminal history background data of all adult household members
20.	Disclosure of the use, sale, distribution or manufacture of illegal drugs of any adult household members
21.	Disclosure of arrests or convictions of the use or illegal distribution or manufacture of illegal drugs or controlled substances
22.	Disclosure of arrests or convictions of a felony or misdemeanor (other than a traffic violation)
23.	Disclosure of lifetime registration as a predatory sex offender of any adult household member
24.	Disclosure of a pattern of alcohol abuse of any adult household member that would interfere with other tenants’ rights
25.	Disclosure of receipt of previously received government housing subsidy
26.	Disclosure of termination of housing assistance for fraud, non-payment of rent or utilities or failure to cooperate with recertification procedures
27.	Current and previous residency

Part B

1.	Race
2.	Ethnicity
3.	Gender of head of household
4.	Marital Status 
5.	Occupation
6.	Receipt of Public Assistance 

Attachment 2
Housing Tax Credit Program

Part A

1.	Household composition, legal name(s), date of birth, and relationship to the head of household of all household members
2.	Student status
3.	Amount and source of all earned and unearned income of all household members
4.	Source, type, value and income derived from all household assets
5.	Type, value and income derived from all household assets disposed of for less than fair market value within the past 2 years
6.	Custody of minor children
7.	Elderly, disabled or handicapped status of affected members of your household (for program eligibility, if applicable)

Part B

1.	Race			
2.	Ethnicity			
3.	Gender of head of household		
4.	Social Security Number or Alien Registration of all household members		 
5.	Elderly, disabled or handicapped status of members of your household
6.	Marital Status
7.	Receipt of Public Assistance
8.	Request and verification of need for reasonable accommodation

Attachment 3
MHFA First Mortgage Loan Programs
ARM, LMIR

Part A

1.	Household composition, legal name(s), date of birth, and relationship to the head of household of all household members
2.	Student status
3.	Employment or unemployment status
4.	Amount and source of all earned and unearned income of all household members
5.	Elderly, disabled or handicapped status of affected members of your household (for program eligibility, if applicable

Part B

1.	Race			
2.	Ethnicity			
3.	Gender of head of household		
4.	Social Security Number or Alien Registration of all household members		 
5.	Elderly, disabled or handicapped status of members of your household
6.	Marital Status
7.	Request and verification of need for reasonable accommodation

Attachment 4
MHFA Deferred Loan Programs
(other than MARIF)

Part A

1.	Household composition, legal name(s)*, age(s) and relationship to the head of household of all household members
2.	Employment or unemployment status
3.	Amount and source of all earned income of all adult household members
4.	Amount and source of all unearned income of all household members
5.	Type, value and income derived from all household assets
6.	Type, value and income derived from all household assets disposed of for less than fair market value within the past 2 years

Part B 

1.	Race			
2.	Ethnicity			
3.	Gender of head of household		
4.	Social Security Number or Alien Registration of all household members		 
5.	Elderly, disabled or handicapped status of affected members of your household
6.	Marital Status
7.	Receipt of Public Assistance

* For purposes of reporting to MHFA under the HOPWA program, participant names are coded for confidentiality.

Attachment 5
Deferred Loan Program
Minnesota Families Affordable Rental Investment (MARIF) 

Part A

1.	Information regarding the household composition including the number of members in your household.
2.	The amount and source of all earned and unearned income of all household members.
3.	The type, value and income derived from all household assets.
4.	The type, value and income derived from all household assets disposed of for less than fair market value within the last 2 years.
5.	Receipt of Public Assistance and/or rent assistance.
6.	Social Security Number or Alien Registration of all household members.
7.	Evidence of current or recent Minnesota Families Investment Program (MFIP) participant.  “Recent MFIP participant” means a family who left MFIP for reasons other than disqualification from MFIP due to fraud no more than twenty-four (24) months prior to the family’s application for tenancy in a MARIF unit, and whose income at the time of application is equal to or less than 160% of the federal poverty level for the family’s size.

Part B

1.	Race
2.	Marital Status
3.	Ethnicity
4.	Previous housing
5.	Request and verification of need for reasonable accommodation
6.	Gender of head of household

Attachment 6
HOME Program

Part A
1.	Information regarding the household composition including the name(s) and age(s) of all members in the household.
2.	The amount and source of all earned and unearned income of all household members
3.	The type, value and income derived from all household assets.
4.	Bedroom Size
5.	Tenant Rent Contribution

Part B 
1.	Race
2.	Ethnicity
3.	Gender of head of household
4.	Receipt of Public Assistance and Type of Assistance (ie Rural Development, Section 8 etc)
5.	Homeless Household
6.	Development Address
7.	Disabled Status
8.	Household Type (i.e., single, elderly, etc. and related single parent)
9.	Unit number household occupies