PRINT, COMPLETE, SIGN & FAX TO (404) 549-4210

USA Affordable Housing Provider
USA Housing Solutions, Inc.
2870 Peachtree Road NW, Suite 474
Atlanta, GA 30305
Phone: (404) 592-0847
Voice Mail: (866) 657-5253
Fax: (404) 549-4210


Name Home Phone (     )
Mailing Address Work Phone (     )
City                            State            Zip Cell / Pager (     )
Social Security # Email Address


I hereby acknowledge and agree that:

I am not an employee of USA Affordable Housing Provider. Therefore, I am responsible for any income tax liability and for notifying the IRS of my earnings.

Either, USA Affordable Housing Provider or I may choose to terminate my participation in the CASH REWARDS PROGRAM at any time and for any reason.

If I earn $600 or more during any calendar year, USA Affordable Housing Provider will issue a 1099 IRS Form for tax purposes as required by law. Further, I will cooperate fully with the preparation of this form by supplying my Social Security Number to USA Affordable Housing Provider as indicated above.