HUD 4736B Section 3 Worker Employer Certfication

Section 3 Employer Certification Form-Public Housing Authority

U.S. Department of Housing and Urban Development Office of Field Policy and Management

HUD FORM 4736B OMB Control Number 2501-XXXXX (Exp. XX/XX/XXXX)

(In compliance with Section 3 of the HUD Act of 1968 and 24 CFR Part 75)

__________________________________________________________________________________________________ Public reporting for this collection of information is estimated to average 0.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information.

Section 3 of the Housing and Urban Development Act of 1968, as amended by the Housing and Community Development Act of 1992 (Section 3), and 12 U.S.C. § 1701u ensure that employment and other economic opportunities generated by Federal financial assistance for housing and community development programs are, to the greatest extent feasible, directed toward low- and very low-income persons, particularly those who receive government assistance for housing. The regulations are found at 24 CFR Part 75. This collection of information is required in order to ensure that a worker can be certified as an eligible Section 3 worker as outlined in 24 C.F.R. § 75.31. The information will be used by the Department to ensure compliance with Section 3 of the HUD Act of 1968 employer certification requirements listed in 24 CFR § 75.31, to assess the results of the Department's efforts to meet the statutory objectives of Section 3, to prepare reports to Congress, and by recipients to ensure they are complying with their recordkeeping requirements found in the regulation, and as a self-monitoring tool.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions to reduce this burden, to Anna P. Guido, Reports Management Officer, QDAM, Department of Housing and Urban Development, 451 7th Street, SW, Room 4176, Washington, DC 20410-5000. When providing comments, please refer to OMB Approval No. XXXX-XXXX. HUD may not conduct and sponsor, and a person is not required to respond to, a collection of information unless the collection displays a valid control number. No assurances of confidentiality are provided for this information collection.

The purpose of this form is to comply with Section 3 of the HUD Act of 1968 employer certification requirements listed in 24 CFR § 75.31. This form is to be filled out by a representative of an employer of a Section 3 worker.

Please provide the following information about the business/employer:

Name of Business: __________________________________________________________________________________

__________________________________________________________________________________________________

Street Address City State Zip

Phone #: ________________________ Email: _________________________________________________

Please provide the following information about the worker/employee:

Printed Name of Worker:

__________________________________________________________________________________________________

Street Address (Not a PO Box) Apt# City State Zip

Phone #: Email:

Please indicate which of the following is true for the worker listed above: (Select all that apply)

____ Worker’s income from your employment is below the income limit based on a calculation of what the worker’s wage rate would translate to if annualized on a full-time basis* ____ Worker is employed by a Section 3 Business Concern (Select if your business qualifies as a Section 3 Business Concern)

Income limit $XX,XXX

*Currently or at the time of hire if hired within the past 5 years

I/We, the undersigned, certify under penalty of perjury that the information provided above is true and correct and certifies that the worker identified above meets the definition of a Section 3 worker. WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil and administrative penalties. (18 U.S.C. §§ 287, 1001, 1010, 1012; 31 U.S.C. §3729, 3802)

_____________________________________________ ___________________________

Signature Date

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