Housing – Authorization for Release of Information Privacy Act Form


Housing - Authorization for the Release of Information / Privacy Act Notice
U.S. Department of Housing and Urban Development Office of Public and Indian Housing
Authorization for the Release of Information/Privacy Act Notice to the U.S. Department of Housing and Urban Development (HUD) and the Housing Agency/Authority (HA)

OMB CONTROL NUMBER: 2501-0014

Authority: Section 904 of the Stewart B. McKinney Homeless
Assistance Amendments Act of 1988, as amended by Section 903
of the Housing and Community Development Act of 1992 and
Section 3003 of the Omnibus Budget Reconciliation Act of 1993.
This law is found at 42 U.S.C. 3544.
This law requires that you sign a consent form authorizing: (1)
HUD and the Housing Agency/Authority (HA) to request verification
of salary and wages from current or previous employers; (2)
HUD and the HA to request wage and unemployment compensation
claim information from the state agency responsible for
keeping that information; (3) HUD to request certain tax return
information from the U.S. Social Security Administration and the
U.S. Internal Revenue Service. The law also requires independent
verification of income information. Therefore, HUD or the HA
may request information from financial institutions to verify your
eligibility and level of benefits.
Purpose: In signing this consent form, you are authorizing HUD
and the above-named HA to request income information from the
sources listed on the form. HUD and the HA need this information
to verify your household’s income, in order to ensure that you are
eligible for assisted housing benefits and that these benefits are set
at the 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 income information it obtains in accordance with the Privacy
Act of 1974, 5 U.S.C. 552a. HUD may disclose information
(other than tax return information) for certain routine uses, such as
to other government agencies for law enforcement purposes, to
Federal agencies for employment suitability purposes and to HAs
for the purpose of determining housing assistance. The HA is also
required to protect the income information it obtains in accordance
with any applicable State privacy law. HUD and HA employees
may be subject to penalties for unauthorized disclosures or improper
uses of the income information that is obtained based on the
consent form. Private owners may not request or receive
information authorized by this form.
Who Must Sign the Consent Form: Each member of your
household who is 18 years of age or older must sign the consent
form. Additional signatures must be obtained from new adult
members joining the household or whenever members of the
household become 18 years of age.
Persons who apply for or receive assistance under the following
programs are required to sign this consent form:
PHA-owned rental public housing
Turnkey III Homeownership Opportunities
Mutual Help Homeownership Opportunity
Section 23 and 19(c) leased housing
Section 23 Housing Assistance Payments
HA-owned rental Indian housing
Section 8 Rental Certificate
Section 8 Rental Voucher
Section 8 Moderate Rehabilitation
Failure to Sign Consent Form: Your failure to sign the consent
form may result in the denial of eligibility or termination of
assisted housing benefits, or both. Denial of eligibility or termination
of benefits is subject to the HA’s grievance procedures and
Section 8 informal hearing procedures.
Sources of Information To Be Obtained
State Wage Information Collection Agencies. (This consent is
limited to wages and unemployment compensation I have received
during period(s) within the last 5 years when I have
received assisted housing benefits.)
U.S. Social Security Administration (HUD only) (This consent is
limited to the wage and self employment information and payments
of retirement income as referenced at Section 6103(l)(7)(A)
of the Internal Revenue Code.)
U.S. Internal Revenue Service (HUD only) (This consent is
limited to unearned income [i.e., interest and dividends].)
Information may also be obtained directly from: (a) current and
former employers concerning salary and wages and (b) financial
institutions concerning unearned income (i.e., interest and dividends).
I understand that income information obtained from these
sources will be used to verify information that I provide in
determining eligibility for assisted housing programs and the level
of benefits. Therefore, this consent form only authorizes release
directly from employers and financial institutions of information
regarding any period(s) within the last 5 years when I have
received assisted housing benefits.

Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form for the purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs that receive income information under this consent form cannot use it to deny, reduce or terminate assistance without first independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In addition, I must be given an opportunity to contest those determinations.
This consent form expires 15 months after signed.
Full Name

Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair Housing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and participants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoring HUD-assisted housing programs, to protect the Government’s financial interest, and to verify the accuracy of the information you provide.
This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatory investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. Penalty: You must provide all of the information requested by the HA, including all Social Security Numbers you, and all other household members age six years and older, have and use. Giving the Social Security Numbers of all household members six years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provide any of the requested information may result in a delay or rejection of your eligibility approval.

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