Authorization for the Release of Information Privacy Act Notice

Status: Original and derived artifacts are available for this document.

Download: docx | pdf | html

								                 OMB Control Number: 2577-0295
OMB Expire XX/XX/XXX

Authorization for the Release of Information/Privacy Act Notice to the U.S. Department of Housing and Urban Development and the Housing Agency/Authority (HA)
U.S. Department of Housing and Urban Development, Office of Public and Indian Housing
_______________________________________________________________________________________________
HA requesting release of information (full address, name of contact person, and date): 



 
Authority: Section 904 of the Stewart B. McKinney Homeless Assistance Amendments Act of 1988, as amended by Section 903 of the Housing and Community Development Act of 1992 and Section 3003 of the Omnibus Budget Reconciliation Act of 1993. This law is found at 42 U.S.C. 3544. This law requires you to sign a consent form authorizing: (1) HUD, and the HA to request verifi­cation of salary and wages from current or previous employers; (2) HUD and the HA to request wage and unemployment compensa­tion claim information from the state agency responsible for keeping that information; and (3) HUD to request certain tax return information from the U.S. Social Security Administration and the U.S. Internal Revenue Service.
Section 104 of the Housing Opportunity and Modernization Act of 2016. The relevant provisions are found at 42 U.S.C. 1437n . This law requires you to sign a consent form authorizing the HA to request verification of any financial record from any financial institutions as defined in the Right to Financial Privacy Act (12 U.S.C. 3401)), whenever the HA determines, the record is needed to determine an applicant’s or participant’s eligibility for assistance or level of benefits. 
Purpose: In signing this consent form, you are authorizing HUD and the above-named HA to request income information from the sources listed on the form. HUD and the HA need this information to verify your household’s income, in order to ensure that you are eligible for assisted housing benefits and 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 income information it obtains in accordance with the Privacy Act of 1974, 5 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 HAs for the purpose of determining housing assistance. The HA is also required to protect the income information it obtains in accordance with any applicable State privacy law. HUD and HA employees may be subject to penalties for unauthorized disclosures or im­proper uses of the income information that is obtained based on the consent form. Private owners may not request or receive information authorized by this form.
Who Must Sign the Consent Form: Each member of your family who is 18 years of age or older must sign the consent form. Additional signatures must be obtained from new adult members joining the family or whenever members of the family become 18 years of age.
Persons who apply for or receive assistance under the following programs are required to sign this consent form:
Public Housing
Housing Choice Voucher
Section 8 Moderate Rehabilitation
Failure to Sign Consent Form: Your failure to sign the consent form may result in the denial of eligibility or termination of assisted housing benefits, or both. Denial of eligibility or termi­nation of benefits is subject to the HA’s grievance procedures and Section 8 informal hearing procedures.
Revocation of consent: If you revoke consent, the PHA will be unable to verify your information, although the data matches between HUD and other agencies will continue to automatically occur in the Enterprise Income Verification (EIV) System if the family is not terminated from the program.
Sources of Information to be Obtained
State Wage Information Collection Agencies. (This consent is limited to wages and unemployment compensation I have received when I have received assisted housing benefits.)
U.S. Social Security Administration (HUD and HA).  (This consent is limited to Social Security number verifications, Title II, Title VIII, and Title XVI benefit information.)
U.S. Internal Revenue Service (HUD only) (This consent is limited to unearned income [i.e., interest and dividends].)
Information may also be obtained directly from: (a) current and former employers concerning salary and wages; and (b) financial institutions as defined in the Right to Financial Privacy Act (12 U.S.C. 3401), whenever the HA determines, the record is needed to determine an applicant’s or participant’s eligibility for assistance or level of benefits.  I understand that income information obtained from these sources will be used to verify information that I provide in determining eligibility for assisted housing programs and the level of benefits. Therefore, this consent form only authorizes release directly from employers and financial institutions of information.
Carefully read this authorization to release information about you, then sign and date.
Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form for the purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs.
I authorize the Social Security Administration (SSA) to verify and disclose to HUD and HAs whether the name, Social Security Number (SSN) and date of birth I have submitted as part of this application matches information in SSA records and to disclose explanatory information identifying the data element(s) that do not match the information in SSA’s records in the event of a discrepancy.  I also authorize SSA to disclose fact of receipt and the Title II, Title VIII, and Title XVI benefit/payment amount issued, if applicable, for the purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs.
I authorize HUD and HAs to request and obtain income information pertaining to me from the U.S. Internal Revenue Service, State Wage Collection Agencies, and other custodians of records or sources of information, for the purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. 
I understand that HAs that receive income information under this consent form cannot use it to deny, reduce or terminate assistance without first independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In addition, I must be given an opportunity to contest those determinations.
This consent form remains effective until the earliest of (i) the rendering of a final adverse decision for an assistance applicant; (ii) the cessation of a participant’s eligibility for assistance from HUD and the PHA; or (iii) The express revocation by the assistance applicant or recipient (or applicable family member) of the authorization, in a written notification to HUD or the PHA. 
Signatures:


Head of Household                                                                   Signature                                  SSN                                             Date of Birth                                    Date
       SSN
Date 
Date
Spouse/Co-head/Other Family Member over age 18               Signature                                  SSN                                             Date of Birth                                    Date  
        
Date
Other Family Member over age 18                                           Signature                                  SSN                                             Date of Birth                                    Date




Other Family Member over age 18                                           Signature                                  SSN                                             Date of Birth                                    Date  
        

Other Family Member over age 18                                           Signature                                  SSN                                             Date of Birth                                    Date


Other Family Member over age 18                                           Signature                                  SSN                                             Date of Birth                                    Date




Other Family Member over age 18                                           Signature                                  SSN                                             Date of Birth                                    Date  
        

Other Family Member over age 18                                           Signature                                 SSN                                              Date of Birth                                    Date
Other Family Member over age 18
Date


Privacy Advisory. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair Housing Act (42 U.S.C. 3601-19). Purpose: This form authorizes HUD and the above-named HA to request income information to verify your household’s income in order to ensure that you are eligible for assisted housing benefits and that these benefits are set at the correct level. This information will be shared to the entities identified on this form pursuant to the consent provided.  This information may also be shared with entities identified in the Inventory Management System, Public and Indian Housing Information Center and Housing Information Portal, available at hud.gov/privacy.  Failure to provide any of the requested information may result in a delay or rejection of your eligibility approval. 

Penalties for Misusing this Consent: HUD and the HA (or any employee of HUD or the HA) 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 the form HUD-9886-A is restricted to the purposes cited on the form HUD-9886-A. 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 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 the HA for the unauthorized disclosure or improper use.

Public Reporting Burden Statement The public reporting burden for this collection of information is estimated to average 0.16 hours for new admissions and .08 hours for household members turning 18, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information.  Comments regarding the accuracy of this burden estimate and any suggestions for reducing this burden can be sent to U.S. Department of Housing and Urban Development, Office of the Chief Data Officer, R, 451 7th St SW, Room 8210, Washington, DC 20410-5000. Do not send completed forms to this address. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the collection displays a valid OMB control number. HUD collects this information for program eligibility determination purposes for Housing Choice Voucher, Public Housing, and Section 8 Moderate Rehabilitation programs. HUD uses this information to ensure the correct levels of federal benefits are paid on behalf of families receiving housing assistance under a covered program. This information is mandatory/required to obtain benefits to so that PHAs can carry out the requirements of Section 904 of the Stewart B. McKinney Homeless Assistance Amendments Act of 1988, as amended by Section 903 of the Housing and Community Development Act of 1992 and Section 3003 of the Omnibus Budget Reconciliation Act of 1993 (42 U.S.C. 3544) and Section 104 of HOTMA to ensure that HUD and PHAs can verify eligibility and income information for applicants and participants. This information collection is protected from disclosure by the Privacy Act.