Consent to Release Information Letter to Third Party

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT

WASHINGTON, DC 20410-6000

OFFICE OF POLICY DEVELOPMENT AND RESEARCH

R
e: ______________________________________________ ID # __________________________

To Whom It May Concern:

The U.S. Department of Housing and Urban Development (HUD) has authorized ICF International under contract # GS-23F-9777H, Task Order # DU208WP-13-T-00002 to gather and verify the information requested on the attached form. The data collection effort has been approved by the Office of Management and Budget and is needed by HUD to carry out its responsibility to monitor its programs. HUD is legally authorized to require that this information be provided. Please provide the information requested on the attached form and return it in the self-addressed postage paid envelope, no later than the date indicated on the attached form.

If you have any questions about completing this form call ICF International (toll free) at 1-877-392-9776 and ask for a member of the data quality staff. If you have questions about the authority to collect this information, call Dr. Yves S. Djoko, HUD Project Officer, at 202-402-5851.

The person named above has given consent to release the information requested.

Consent to Release Information

I, (print name) _______________________________ authorize the release of information on the attached form to ICF International.

Signature: ________________________________________________ Date: _____/_____/______

The consent to release information does not authorize the payment of any fees to you or your institution by us or the person named above. If a fee is required to obtain the requested information please make a note on the attached form and return the form in the envelope provided.

The information that you provide will be kept confidential. HUD (or any HUD representative) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Any person, who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or tenant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or tenant 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 or HUD representative responsible for the unauthorized disclosure or improper use.

Notice: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the United States as to matters within its jurisdiction.

Return to ICF International, Attention: HUD Quality Control Study

530 Gaither Road, Suite 500, Rockville, MD 20850

Toll free telephone number: (877) 392-9776 Toll free fax number: (800) 823-0127

FY 2013 Third Party Release Letter

October 2013