Authorization For The Release Of Information-PDF Free Download

Authorization for the Release of Information
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Request for Change in Family Composition, Name of Head of Household Date. Client ID Social Security, Phone E mail Address, REMOVE from household Please provide full name and new address of person being removed. NAME First and Last NEW ADDRESS REASON, Please Print. ADD to household Please provide full name of person being added and complete all fields. NAME First and Last GENDER REASON, Male Female, Relationship to Head of Household. Date of Birth Month Day Year, Does this person have ANY source of.
Social Security income, Does this person have ANY dependents. Please attach Supporting documents of proof If all documents are not provided the request will not be processed. Adding 18 years, 18 years or older, or older Removing over 18 years. ChangeofofFamily, Change FamilyComposition, Composition FormForm Proof. ProofofofIncome, Income Change, of Family Composition. CompositionForm, BirthCertificate, Birth Certificate Social.
Social Security, Security Card, Card Declaration, Declaration Form. Statepicture, State pictureIDID Must, Mustbebe valid. valid CriminalBackground, Criminal Background Form. Form Death, DeathCertificate, Certificate Obituary. USDeclaration, US DeclarationofofCitizenship, Citizenship Form Disposal.
Form DisposalofofAssets, Assets form, form 1 Copy of updated State ID or utility bill for family member. HUDAuthorization, Authorizationofof Release of of, Release Information. Informationformform removed showing their new address. Letterorornew, fromOwner Manager, Owner Manager approving. approving request, request AND, Addingunder, Adding under1818 years. years of Age, Age Lease or letter of HCVP participant from your Owner Manager.
ChangeofofFamily, FamilyComposition, Composition Form. Form Birth Certificate, Birth Certificateor or, Birth facts. Birth facts showing removal from household, SocialSecurity. SecurityCard, USDeclaration, DeclarationofofCitizenship. CitizenshipForm, CourtAwarded, Awarded Notarized, Notarizedletter.
letteror or, Power of Attorney, Power of AttorneyNOTNOT. Acceptable, Acceptable 2 Lease or letter from new Owner Manager of family member. removed or statement from the person they are living with. Lease or letter of HCVP participant from your Owner Manager. Showing removal from household, Signature of Head of Household Removing Under 18 years of Age with Income. Change ofFamily, FamilyComposition, CompositionForm. Written letter Proof of Address Must, Written letter Proof of Address Must provide.
provide both, Proof ofBeneficiary, Beneficiarychange. change Child, Child support, support SSI SSI TANF, Date Death. DeathCertificate, Certificate Obituary, Removing Under 18 years of Age with no income. Change of Family Composition Form, Death Certificate Obituary. Housing Choice Voucher Program, DECLARATIONS, Please Print.
Client s Name, Social Security, I would like to declare the following. Your Signature Date, Your address, Your phone, CHANGE IN FAMILY COMPOSITION 3RD PARTY VERIFICATION. CONTACT INFORMATION, This form must be completed, Client Name Client. Employment If applicable Previous or Current, Corporate Company Name. Corporate Company Address, Phone number Fax, Address of actual work location.
Contributions If applicable, Contributors Name, Contributors Address. School Verification If applicable 18 and older, Name of School. School address, Child Care Provider If applicable, Name of Child Care Provider. Child Care Providers address, Child Support all filed child support orders regardless of whether payment is received and proof of. Unemployment Benefits If applicable, Did you apply for unemployment benefits.
Yes Attach status letter, No Must apply and provide proof. Start Date, Weekly Benefit Amount, Housing Choice Voucher Program. SCHOOL VERIFICATION, Due back by, Date Client Name Client. Student Name, Student SS, The household member named above has applied for or is recertifying eligibility for housing assistance under a program of the U S. Department of Housing and Urban Development HUD HUD requires us to verify all information that is used in determining the. person s eligibility or level of benefits, Please make sure to include this completed form with your request for change along with a copy of the student class schedule.
I consent to allow The Houston Housing Authority to request and obtain the 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, ATTENDANCE OFFICE OR ADMISSIONS OFFICE PLEASE COMPLETE THE FOLLOWING. This student is attending, If attending College University or Trade School. Number of hours per semester, Title 18 Section 1001 of the U S Code states that a person is guilty of a felony for knowingly. and willingly making false or fraudulent statements to any department of the United States Government. HHA APPLICANT TENANT CERTIFICATION FOR CHILDCARE, EXPENSES Client Name Client. I We hereby certify that the following represent true and accurate statements regarding our household. circumstances related to childcare, Child children cared for are under 13 years of age.
Reason for care check one, Such care enables the following family member to work. Occupation, Employer address phone number, Hours worked per week month. Such care enables a family member to attend vocational or academic courses. Member s name, Institution name address phone, Hours at school. Childcare costs are not paid to anyone living in our household they are paid to. Address Phone, I We do not receive reimbursement for childcare costs from any agency or individual outside the. I We recognize that the above statements are subject to third party verification. HHA CHILDCARE VERIFICATION, Individual Babysitter provides Care.
Dear Sir Madam, has applied for or is a participant in the Housing Choice Voucher. Please fill in the blanks below and return this letter to us as soon as possible All information is. confidential and is only used to help determine the participant s housing subsidy. Name s and age s of child ren cared for, Name of Child Care Provider. Phone Contact Person, Childcare is provided on the following days for the hours indicated. Monday hours Tuesday hours, Wednesday hours Thursday hours. Friday hours Saturday hours, Sunday hours, Total hours per week Total hours per month.
Cost of Care per week month, received for care from family named above week month. received for care from others if any week month, Name of individual program or other third party source providing childcare funds for this family. Estimated cost of care to the family for the upcoming 12 months. Signature Date, TENANT APPLICANT RELEASE, I hereby authorize the release of the requested information. Signature Date, Authorization for the Release of Information U S Department of Housing. and Urban Development, Privacy Act Notice Office of Public and Indian Housing.
to the U S Department of Housing and Urban Development HUD. OMB CONTROL NUMBER 2501 0014, and the Housing Agency Authority HA. PHA requesting release of information Cross out space if none IHA Requesting Release of information of information Cross out space if none. Full address name of contact person and date full address name of contact person and date. Houston Housing Authority, 2640 Fountain View Suite 100. Houston TX 77057, Authority Section 904 of the Stewart B McKinney Homeless. Assistance Amendments Act of 1988 as amended by Section 903 Persons who apply for or receive assistance under the following. of the Housing and Community Development Act of 1992 and programs are required to sign this consent form. Section 3003 of the Omnibus Budget Reconciliation Act of 1993 PHA owned rental public housing. This law is found at 42 U S C 3544, Turnkey III Homeownership Opportunities. This law requires that you sign a consent form authorizing 1 Mutual Help Homeownership Opportunity. HUD and the Housing Agency Authority HA to request verifi. cation of salary and wages from current or previous employers 2 Section 23 and 19 c leased housing. HUD and the HA to request wage and unemployment compensa Section 23 Housing Assistance Payments. tion claim information from the state agency responsible for HA owned rental Indian housing. keeping that information 3 HUD to request certain tax return. information from the U S Social Security Administration and the Section 8 Rental Certificate. U S Internal Revenue Service The law also requires independent Section 8 Rental Voucher. verification of income information Therefore HUD or the HA Section 8 Moderate Rehabilitation. may request information from financial institutions to verify your. eligibility and level of benefits Failure to Sign Consent Form Your failure to sign the consent. form may result in the denial of eligibility or termination of. Purpose In signing this consent form you are authorizing HUD assisted housing benefits or both Denial of eligibility or termi. and the above named HA to request income information from the nation of benefits is subject to the HA s grievance procedures and. sources listed on the form HUD and the HA need this information Section 8 informal hearing procedures. to verify your household s income in order to ensure that you are Sources of Information To Be Obtained. eligible for assisted housing benefits and that these benefits are set. at the correct level HUD and the HA may participate in computer State Wage Information Collection Agencies This consent is. matching programs with these sources in order to verify your limited to wages and unemployment compensation I have re. eligibility and level of benefits ceived during period s within the last 5 years when I have. received assisted housing benefits, Uses of Information to be Obtained HUD is required to protect.
U S Social Security Administration HUD only This consent is. the income information it obtains in accordance with the Privacy. limited to the wage and self employment information and pay. Act of 1974 5 U S C 552a HUD may disclose information. ments of retirement income as referenced at Section 61. other than tax return information for certain routine uses such as. 03 l 7 A of the Internal Revenue Code, to other government agencies for law enforcement purposes to. Federal agencies for employment suitability purposes and to HAs U S Internal Revenue Service HUD only This consent is. for the purpose of determining housing assistance The HA is also limited to unearned income i e interest and dividends. required to protect the income information it obtains in accordance. with any applicable State privacy law HUD and HA employees Information may also be obtained directly from a current and. may be subject to penalties for unauthorized disclosures or im former employers concerning salary and wages and b financial. proper uses of the income information that is obtained based on the institutions concerning unearned income i e interest and divi. consent form Private owners may not request or receive dends I understand that income information obtained from these. information authorized by this form sources will be used to verify information that I provide in. determining eligibility for assisted housing programs and the. Who Must Sign the Consent Form Each member of your level of benefits Therefore this consent form only authorizes. household who is 18 years of age or older must sign the consent release directly from employers and financial institutions of. form Additional signatures must be obtained from new adult information regarding any period s within the last 5 years. members joining the household or whenever members of the when I have received assisted housing benefits. household become 18 years of age, 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 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 expires 15 months after signed, Signatures. Head of Household Date, Social Security Number if any of Head of Household Other Family Member over age 18 Date. Spouse Date Other Family Member over age 18 Date, Other Family Member over age 18 Date Other Family Member over age 18 Date.
Other Family Member over age 18 Date Other Family Member over age 18 Date. Privacy Act Notice 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 The Housing and Community Development Act of 1987 42 U S C 3543 requires applicants and participants to. submit the Social Security Number of each household member who is six years old or older Purpose Your income and other info rmation are

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