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Housing Quality Standards Certification

[{"type":"text","label":"I, the Owner/Agent of this property,","name":"owneragent-name","className":"col-lg-4","subtype":"text"},{"type":"date","required":true,"label":"Certify that all deficiencies from the inspection on","name":"Certify-that-all-deficiencies-from-the-inspection-on","className":"col-lg-4"},{"type":"text","required":true,"label":"For (Tenant Name)","name":"tenant-name","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"At this address","name":"address","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"Address City","name":"address-city","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"select","required":true,"label":"Address State","name":"address-State","className":"col-md-6 col-lg-3","values":[{"label":"Alabama","value":"AL"},{"label":"Alaska","value":"AK"},{"label":"Arizona","value":"AZ"},{"label":"Arkansas","value":"AR"},{"label":"California","value":"CA"},{"label":"Colorado","value":"CO"},{"label":"Connecticut","value":"CT"},{"label":"Delaware","value":"DE"},{"label":"District of Columbia","value":"DC"},{"label":"Florida","value":"FL"},{"label":"Georgia","value":"GA"},{"label":"Hawaii","value":"HI"},{"label":"Idaho","value":"ID"},{"label":"Illinois","value":"IL"},{"label":"Indiana","value":"IN"},{"label":"Iowa","value":"IA"},{"label":"Kansas","value":"KS"},{"label":"Kentucky","value":"KY"},{"label":"Louisiana","value":"LA"},{"label":"Maine","value":"ME"},{"label":"Maryland","value":"MD"},{"label":"Massachusetts","value":"MA"},{"label":"Michigan","value":"MI"},{"label":"Minnesota","value":"MN"},{"label":"Mississippi","value":"MS"},{"label":"Missouri","value":"MO"},{"label":"Montana","value":"MT"},{"label":"Nebraska","value":"NE"},{"label":"Nevada","value":"NV"},{"label":"New Hampshire","value":"NH"},{"label":"New Jersey","value":"NJ"},{"label":"New Mexico","value":"NM"},{"label":"New York","value":"NY"},{"label":"North Carolina","value":"NC"},{"label":"North Dakota","value":"ND"},{"label":"Ohio","value":"OH"},{"label":"Oklahoma","value":"OK"},{"label":"Oregon","value":"OR"},{"label":"Pennsylvania","value":"PA"},{"label":"Rhode Island","value":"RI"},{"label":"South Carolina","value":"SC","selected":true},{"label":"South Dakota","value":"SD"},{"label":"Tennessee","value":"TN"},{"label":"Texas","value":"TX"},{"label":"Utah","value":"UT"},{"label":"Vermont","value":"VT"},{"label":"Virginia","value":"VA"},{"label":"Washington","value":"WA"},{"label":"West Virginia","value":"WV"},{"label":"Wisconsin","value":"WI"},{"label":"Wyoming","value":"WY"}]},{"type":"text","required":true,"label":"Address Zip","name":"address-zip","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"header","subtype":"h4","label":"Have been corrected/repaired/replaced.","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"date","required":true,"label":"Date Repairs Completed","name":"Date-repairs-completed","className":"d-block"},{"type":"text","label":"Owner/Agent Signature (by typing your name you are signing this form)","name":"owner-or-agent-signature","className":"col-md-6","subtype":"text"},{"type":"text","label":"Head of Household Signature (by typing your name you are signing this form)","name":"Head-of-Household-Signature","className":"col-md-6","subtype":"text"},{"type":"date","label":"Owner/Agent Signature Date","name":"owner-or-agent-signature-date","className":"col-md-6"},{"type":"date","label":"Head of Household Signature Date","name":"Head-of-Household-Signature-Date","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"For PHA Use Only!","className":"d-block"},{"type":"paragraph","subtype":"p","label":"The PHA verified with the participant that deficiencies have been corrected.","className":"d-block"},{"type":"text","label":"PHA Signature","placeholder":"For PHA use only.","name":"PHA-Signature","className":"col-md-6","subtype":"text"},{"type":"date","label":"PHA Signature Date","name":"PHA-Signature-Date","className":"col-md-6"}]

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