Debts Owed to Public Housing Agencies and Terminations

OMB No. 25077-XXXX

Expires: MM/DD/YYYY

U.S. Department of Housing and Urban Development
Office of Public and Indian Housing

Paperwork Reduction Notice: The information collection requirements contained in this notice have been approved by the
Office of Management and Budget (OMB under the Paperwork Reduction Act of 1995 (44 U.S.C. 3520) and assigned OMB
control number(s) 2577-XXXX. In accordance with the Paperwork Reduction Act, HUD may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless the collection displays a currently valid OMB control
number.

NOTICE TO APPLICANTS AND PARTICIPANTS OF THE FOLLOWING HUD RENTAL ASSISTANCE PROGRAMS:
• Public Housing
• Housing Choice Voucher
• Section 8 Moderate Rehabilitation
• Project-Based

DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS
The U.S. Department of Housing and Urban Development maintains a national repository of debts owed to PHAs and
adverse termination of former participants of the above-listed HUD rental assistance programs. This information is
maintained within HUD’s Enterprise Income Verification (EIV) system, which is used by Public Housing Agencies
(PHAs) to verify employment and income information of program participants, as well as, to reduce administrative
and rental assistance payment errors. The EIV system is designed to assist PHAs and HUD in ensuring that families
are eligible to participate in HUD rental assistance program and determining the correct amount of rental assistance
a family is eligible for. All PHAs are required to use this system.
HUD requires PHAs, which administers the above-listed rental housing programs, to report certain information at
the conclusion of your participation in a HUD rental assistance program. This notice provides you with information
on what information the PHA is required to provide HUD, who will have access to this information, how this
information is used and your rights. PHAs are required to provide this notice to all applicants and program
participants.
What information about you and your tenancy does HUD collect from the PHA?
The following information is collected about each member of your household (family composition):
1. Full Name; and
2. Date of Birth; and
3. Social Security Number
The following information is collected once your participation in the housing program has ended or your move-out
of an assisted unit:
1. Amount of any balance you owe the PHA (up to $500,000); and
2. Whether or not you have entered into a repayment agreement for the amount that you owe the PHA; and
3. Whether or not you have filed for bankruptcy; and
4. The negative reason for your end of participation in the housing program (for example: abandoned unit,
fraud, criminal activity, failure to comply with lease, etc.)

September 2009

Form HUD-XXXX

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Who will have access to the information collected?
This information will be available to HUD employees, PHA employees, and contractors of HUD and PHAs.
How will this information be used?
PHAs will have access to this information during the time of application for rental assistance. PHAs will be able to
access this information to determine a family’s suitability for rental assistance, and avoid providing limited Federal
housing assistance to families who have previously been unable to comply with HUD program requirements. If the
reported information is accurate, your future request for HUD rental assistance may be denied for a period of up to
ten years from the date you moved out of an assisted unit or were terminated from a housing program.
What are my rights?
In accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to its
implementation of the Federal Privacy Act of 1974 (24 CFR Part 16), you have the following rights:
1. To have access to your records maintained by HUD.
2. To have an administrative review of HUD’s initial denial of your request to have access to your records
maintained by HUD.
3. To have incorrect information in your record corrected upon written request.
4. To file an appeal request of an initial adverse determination on correction or amendment of record request
within 30 calendar days after the issuance of the written denial.
5. To have your record disclosed to a third party upon receipt of your written and signed request.
What do I do if I dispute the debt or termination information reported about me?
The debt owed and/or termination information was reported by the above-listed Public Housing Agency (PHA). The
PHA’s name, address, and telephone numbers are listed below. You should contact the PHA in writing if you
disagree with the reported information. Inform the PHA why you dispute the information and provide any
documentation that supports your dispute. Your filing of bankruptcy will not result in the removal of debt owed or
termination information from HUD’s EIV system. However, if you have included this debt in your bankruptcy filing
and/or this debt has been discharged by the bankruptcy court, your record will be updated to include the
bankruptcy indicator. The PHA will notify you of its action regarding your dispute. If the PHA determines that the
disputed information is incorrect, the PHA will update or delete the record. If the PHA determines that the disputed
information is correct, the PHA will provide a written explanation as to why the information is correct.
Important Information:
• Upon your request, the PHA must give you the information that pertains to you and maintained in HUD’s EIV
system.
• All PHAs that administer the Public Housing and Housing Choice Voucher (HCV) programs have access to
debts owed and termination information of all former program participants.
• If you tell the PHA that your record contains inaccurate information, the PHA must promptly investigate the
matter and inform you in writing the outcome of their investigation.
• The PHA must correct or, as the case may be, delete inaccurate debt owed or termination information
contained in the EIV system.
• Debt owed and/or termination information will be maintained in EIV for a period of ten (10) years from the
end of participation date.
This Notice was provided by the below-listed PHA:

I hereby acknowledge that the PHA provided me with this
notice:
Signature

Date

Printed Name
September 2009

Form HUD-XXXX