Loading...
HomeMy WebLinkAboutRRP authorization form Authorization for the Release of Information PHA Requesting release of information: County of Hawai`i Office of Housing and Community Development 1990 Kino`ole Street, Suite 102 Hilo, Hawai`i 96720 (808)961-8379 Authority: 42 U.S.C. 1437f and 3535(d), implemented at 24 CFR Failure to Sign Consent Form: Your failure 982.551(b). to sign the consent form may result in the denial of eligibility or termination 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. limited: to identity and marital status, employment income, welfare income, assets, residences and rental activity, Medical or Child Care Allowances, Credit and Criminal Activity. HUD and Sources of Information: The groups or the HA need this information to verify your eligibility for individuals that may be asked to release assisted 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 in 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 PHAs) information it obtains in accordance with the Privacy Act or 1974, Courts and Post Offices 5 U.S.C. 552a. HUD 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 determining housing assistance. The HA is also required to protect Welfare Agencies the information it obtains in accordance with any applicable State State Unemployment Agencies privacy law. HUD and HA employees may 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 member of your household who Banks and Financial Institution is 18 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 18 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 assisted housing programs. I understand that HAs that receive information under this consent form cannot use it to deny, reduce or terminate assistance 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: ________________________________ _________________ __________________________________ ____________ Head of Household Date Other Family Member over age 18 Date ________________________________ _________________ __________________________________ ____________ Spouse Date Other Family Member over age 18 Date ________________________________ _________________ __________________________________ ____________ Other Family Member over age 18 Date Other Family Member over age 18 Date Penalties for Misusing this Consent: HUD, the HA and any owner (or any employee of HUD, the HA or the owner) may be subject to penalties 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 who knowingly or willfully request, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not 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 may be appropriate, against the officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use. 2/2004 Original is retained by the requesting organization.