Fiesta Manor Application Form

I/we certify that the information given to Moline Housing Authority on household composition, rental history and gross family income/assets is accurate and complete to the best of my/our knowledge and belief. I/we understand that 19 U.S.C. 1001 provides, among other things, that whoever knowingly and willfully makes or uses a document or writing containing false, fictitious or fraudulent statement or entry in any matter within the jurisdiction of a department or agency of the United States shall be fined not more than $10,000 or imprisoned for not more than five (5) years or both.