Final - 2528-0297_Affidavit of Nondisclosure3

OMB #2528-0297

Date: XX-XX-XXXX

Affidavit of Nondisclosure

Date: ______________________________

Project Title:__________________________________________________________________

DL Number (if known): ______________________________________________________

Name: _______________________________________________

Title: ________________________________________________

Organization Name: _____________________________________________________

Organization Address: ______________________________________________________

I, __________________________________ , do solemnly swear (or affirm) that when given access to the subject HUD database or file, I will not –

(i) use or reveal any individually identifiable information furnished, acquired, retrieved or assembled by me or others for any purpose other than statistical, research, or evaluation purposes specified in the approved data license application;

(ii) make any disclosure or publication whereby a sample unit or survey respondent could be identified or the data furnished by or related to any particular person under these sections could be identified; or

(iii) permit anyone other than the individuals authorized by HUD to examine the individual reports.

[Under the Privacy Act, unlawful disclosure of PII data is a misdemeanor and subject to a fine of up to $5,000.]

___________________________________

(Signature)

City/County of _________________ Commonwealth/State of ________________ .

Sworn to and subscribed before me this _______________ day of _______________, 20________ . Witness my hand and official Seal.

_____________________

(Signature of Notary)

(Notary Public/Seal) My commission expires__________________

* Applicants must request all subsequent follow-up data that may be needed. This form cannot be amended by HUD, so access to datasets not listed will require submitting additional notarized Affidavits.

Paperwork Reduction Act Notice. Public reporting burden for this collection of information is estimated to be 15 minutes per applicant, and includes time for reviewing the instructions, and completing and reviewing the responses. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Reports Management Officer, Paperwork Reduction Project (2528-0297), U.S. Department of Housing & Urban Development, 451 7th Street, SW, Washington, DC 20410-3600. The purpose of this information collection is to further policy-relevant research on the effectiveness of HUD’s programs. This information will enable HUD to assure the non-disclosure of protected information. There are no assurances of confidentiality. 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.