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Authorization for the Release of Information PHA. Requesting release of informationz County of Hawaii Office of Housing and Community Development 50 Wailuko Drive Hilo, Hawaivi 96720 808/961-8379 Authority: 42 U.S.C. 1437f and 3535dd) , implemented. at 24 CFP. Failure to Sign Consent Form: Your failure! 982.55l(b) . to sign the consent form may result in the denial of eligibility or temminatio:n of assisted housing benefits, or both. Denial of Purpose: In signing this consent. form, you are authorizing HUD eligibility or termination of benefits is and the above. named HA to request information including but not subject to the HA's grievance procedures. limitedo to identity and marital. status, employment income, welfare income, assets, residences angrental activity, Medical or Child Care Allowances, Credit and Criminal Activity. HUD and. Sources of Information: The groups or the MA. need this information to verify your eligibility for individuals that may be asked to release aasisted housing benefits and that these benefits are set at the information include but are not limited to correct level. HUD and the HA may participate i:n computer matching programs with these sources in order to verify your eligibility and level of benefits. Uses of Information to be Obtained: HUD is required to protect the Previous Landlords (including PHAs1 information it obtains in accordance with the Privacy Act or 1974., Courts and. Post Offices 5 U.S.C. 552a. BUD may disclose information (other than, tax return Schools and Colleges information) for certain routine uses, such as to other government Law Enforcement Agencies agencies for law enforcement purposes, to Federal agencies for Support and Alimony Providers employment, suitability purposes and to HAs for the purpose of Past and Present Employers determinind housind assistance, The HA io also required to proteot Welfare Agencies the information it obtains in accordance with any applicable State State Unemployment! Agencies privacy law. HUD and HA, employees m' be subject to penalties for Social. Security Administration. unauthorized disclosures or improper uses of the information, that is Medical. and. Child Care Providers obtained based on the consent form. Veterans Administration Retirement Systems Who Must Sign the Consent Form: Each memberof your household who Dents and other Financial institution. is 19 years of age or older must sign the consent form. Additional Credit Providers and. Credit Bureaus signatures must be obtained. from new adult members Joining the Utility Companies household or whenever members of the household become 19 years of age. Consent: I consent to allow HUD or the HA to request and obtain any information from any Federal, State or local agency, organization, business, or individual for the purpose of verifying my eligibility and level of benefits under HUD's ' ted housing programs. I understand that HA. that receive information under this consent form cannot use it to deny, reduce or terminate ' tance without first independently verifying the information obtained. In addition, I must be given an opportunity to contest those determinations. This consent form expires 15 months after signed, Signatures; oc, . Head of HO us eth.o id ' Co c e 0 h t F1vn i..(Y('ttFti.he r Q V 0 i ;!,1,4 e 15 t......................................................................................................................................................................................................................................................................................._ 11.M"t-e 14101131E Other Fa mily Re rAN'tt over ,6,,, gr Date WiTchl: 111-1; 11Fi; iV12117e Other Family Mombet love17go 18 . .......................................................................................... Date Penalties for Misusing this Consent: HUD, the HA, and any owner dor any employee of RIM, the HA, or the owner) may be subject topenalties for unauthorized disclosures or improper uses of information collected. based, on the consent form. Use of the information collected based on this form is restricted, to the purposes cited above. Any person whoknowingly or willfully request, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanorand finednot more that $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as mal be appropriate, against the officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use. 2/21104 Original is retained, by the requesting. organization. 62)8thia