EmailMe Form - HCV: Authorization for the Release of Information

Consent: I consent to allow HUD or the Housing Authority of San Angelo (HASA) 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 the HASA, 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.

Sources of Information: The groups or individuals that may be asked to release the authorized information include, but are not limited to: Previous Landlords (Including Public Housing Authorities), Schools and Colleges, Support and Alimony Providers, Welfare Agencies, Social Security Administration, Veteran's Administration, Banks and Other Financial Institutions, Utility Companies, Courts and Post Offices, Law Enforcement Agencies, Past and Present Employers, State Unemployment Agencies, Medical and Child Care Providers, Retirement Systems, Credit Providers and Credit Bureaus, and Data Bases.

This consent expires 15 months after signed.

Name of Head of Household *

First Last

Date

MM / DD / YYYY

Head of Household Signature *

Clear

Spouse/Co-Head Signature

Clear

Other Family Member over 18 Signature

Clear

Other Family Member over 18 Signature

Clear

Other Family Member over 18 Signature

Clear

This authorization is made pursuant to the following:

Authority: 42 U.S.C. 1437f and 3535 (d), implemented at 24 CFR 982.551(b)

Purpose: In signing this consent form, you are authorizing HUD and the above HA to request information, including, but not limited to: identity and marital status, employment income, welfare income, assets, residence and rental activity, medical or child care allowances, credit and criminal activity. HUD and the HA need this information to verify your eligibility for assisted housing benefits, and to ensure 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 information it obtains in accordance with the Privacy Act of 1974, 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 the HASA for the purpose of determining housing assistance. The HASA is also required to protect the information it obtains in accordance with any applicable State privacy laws. HUD and HASA employees may be subject to penalties for authorized disclosures or improper uses of the information that is obtained based on the consent form.

Who Must Sign the Consent Form: Each member of your household who is 18 years of age or older must sign the consent forms. Additional signatures must be obtained from new adult members joining the household or whenever members of the household become 18 years of age.

Failure to Sign Consent Form: Your failure to sign the consent form may result in the denial or termination of rental assistance, and is subject to the HASA's review and hearing procedures for the Public Housing and Housing Choice Voucher (HCV) Programs.

Sources of Information: The groups or individuals that may be asked to release the authorized information include, but are not limited to: Previous Landlords (Including Public Housing Authorities), Schools and Colleges, Support and Alimony Providers, Welfare Agencies, Social Security Administration, Veteran's Administration, Banks and Other Financial Institutions, Utility Companies, Courts and Post Offices, Law Enforcement Agencies, Past and Present Employers, State Unemployment Agencies, Medical and Child Care Providers, Retirement Systems, Credit Providers and Credit Bureaus, and Data Bases.

Penalties for Misusing this Consent: HUD, the HASA, and any owner (or any employee of HUD, the HASA 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 requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosures of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the HASA, or the owner responsible for the unauthorized disclosure or improper use.

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