LOW-INCOME HOUSING TAX CREDIT PROGRAM
DISPLACED INDIVIDUALS CERTIFICATION

I, 	, hereby certify that:

1.	My household was displaced as a result of a Major Disaster;

2.	The address listed below was my principal residence at the time of the Major Disaster and is in an area designated as eligible for Individual Assistance by the Federal Emergency Management Agency (“FEMA”) due to the Major Disaster. The affected address is:

3.	The Displaced Individual(s) in my household and their Social Security Numbers are:

Name		Social Security Number		Name		Social Security Number	
Name		Social Security Number		Name		Social Security Number	
Name		Social Security Number		Name		Social Security Number	
4.	I understand that the housing assistance being offered to me is temporary and will terminate on or before June 30, 2026, and that, if my household chooses to remain in the unit after the end of the temporary housing assistance period, all household members will be expected to be certified as eligible under the Low-Income Housing Tax Credit Program. If my household is not eligible, I/we will promptly vacate the unit.

Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. I understand that providing false representations herein constitutes an act of fraud and Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to willfully falsify a material fact or make a false statement in any manner within the jurisdiction of a federal agency. Further, false, misleading or incomplete information may result in termination of tenancy.

PRINTED NAME	SIGNED NAME

MANAGEMENT USE ONLY
Date Occupancy Began:		Date Occupancy Ended:	
Unit #/Address Occupied:	
Andrew Jackson Building Third Floor - 502 Deaderick St. - Nashville, TN 37243
 www.THDA.org - (615) 815-2200 - Toll Free: 800-228-THDA