Data File Destruction Form

OMB #2528-0297

Date XX-XX-XXXX

HUD Office of Policy Development and Research (PD&R) Data
Destruction Certification Form

This certification attests to the destruction of all HUD data covered by the Data Licensing Agreement (DLA) listed below. Data destruction must encompass any and all original files, all copies made of the files, any derivatives¹ or subsets of the files and any manipulated files ever under the control of individuals allowed by the Licensee organization to have access to the data. All files in all media containing any personally identifying information from the HUD files listed below have been destroyed, and no person associated with the licensee organization, has retained such information in any form.² PD&R will provide e-mail confirmation of receipt of this certification to the principal project officer.

As the principal project officer and on behalf of the

(Licensee organization) , I affirm that the following files received under DLA Number ___, and, as applicable,

all copies, derivatives, subsets and manipulations of those files, whether in electronic or paper form, held by the

(Licensee organization) and/or any individual who had access to those files, have been destroyed.

HUD File/Document Date Destroyed

Principal Project Officer,

Signature Date

Return this signed form to:

Government Technical Representative

HUD-PD&R

451 7^th Street SW

Washington, DC 20410

¹ A derivative file is one containing any piece of Personally Identifying Information from HUD, or any other piece of information from HUD from which an individual identity can be inferred when used in combination with information available from other sources.

² An encrypted, password-protected data file may be transmitted to a designated representative of HUD for safekeeping, if the Licensee desires.

Paperwork Reduction Act Notice. Public reporting burden for this collection of information is estimated to be 1 hour per applicant, and includes time for reviewing the instructions, and completing and reviewing the responses. Your completion of this information collection is voluntary. HUD may not collect this information, and you are not required to complete this form, unless it displays a current, valid OMB control number.