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Home My WebLink About2017 RRP Authorization for the Release of Information Form Authorization for the Release of Information PHA Requesting release of information: County of Hawai`i Office of Housing and Community Development 50 Wailuku Drive 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 other 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. 6238rbla Residential Emergency Repair Program Certification of Non-Filing of Federal Income Tax Return Name:_______________________________ Name:_______________________________ Address:_____________________________ _____________________________ STATE OF HAWAI'I ) ) SS: COUNTY OF HAWAI'I ) The undersigned hereby certify that the borrower (s), pursuant to the laws and regulations as established by the United States Internal Revenue Service (IRS), did not file a Federal Income Tax Return for the tax year __________, and that the borrower (s) understand that misrepresentation of information or failure to disclose information will constitute just cause for the County to call the loan immediately due and payable. ___________________________________ BORROWER ___________________________________ BORROWER Subscribed and sworn to before me this_______ day of ________________, 20_____ ________________________________________ Notary Public, State of Hawai'i My commission expires:_____________________ Residential Emergency Repair Program Certification of Non-Filing of State Income Tax Return Name:_______________________________ Name:_______________________________ Address:_____________________________ ______________________________ STATE OF HAWAI'I ) ) SS: COUNTY OF HAWAI'I ) The undersigned hereby certify that the borrower (s), pursuant to the laws and regulations as established by the State of Hawai'i Department of Taxation, did not file a State Income Tax Return for the tax year __________, and that the borrower (s) understand that misrepresentation of information or failure to disclose information will constitute just cause for the County to call the loan immediately due and payable. ___________________________________ BORROWER ___________________________________ BORROWER Subscribed and sworn to before me this_______ day of ________________, 20____. ________________________________________ Notary Public, State of Hawai'i My commission expires:_____________________ County of Hawai`i Office of Housing and Community Development 1990 Kino’ole Street, Suite 105 Hilo, Hawai'i 96720 (808) 959-4642 Application No._____ RESIDENTIAL EMERGENCY REPAIR PROGRAM VERIFICATION OF MORTGAGE OR DEED OF TRUST The client identified below has applied for a housing rehabilitation loan from the Office of Housing and Community Development (OHCD). The applicant has authorized the OHCD in writing to obtain verification of the status of existing mortgages on the property from any source named in the application. The requested information in this verification of mortgage is for the confidential use of the OHCD and the U.S. Department of Housing and Urban Development. Please furnish the information requested below and return this form using the stamped, addressed envelop provided. If you have any questions please feel free to contact our office. Thank you for your cooperation. County of Hawai`i Office of Housing and Community Development 1990 Kino’ole Street, Suite 105 Hilo, Hawai'i 96720 808/959-4642 PART I. Applicant Information (To be completed by applicant) Name of Applicant _____________________________________________________ Address of Applicant _____________________________________________________ _____________________________________________________ Address of Mortgaged Property_____________________________________________________ _____________________________________________________ Mortgage Account Number _____________________________________________________ PART II. Lender Information (To be completed by applicant) Name of Lender _____________________________________________________ Address of Lender _____________________________________________________ _____________________________________________________