EmailMe Form - HCV: Authorization for the Release of Information

Consent: I consent to allow HUD or the Housing Authority of San Angelo (HASA) to request and obtain any information from any Federal, State, or local agency, organization, business, or individual for the purpose of verifying my eligibility and level of benefits under HUD's assisted housing programs. I understand that the HASA, under this consent form, cannot use it to deny, reduce or terminate assistance without first independently verifying the information obtained. In addition, I must be given an opportunity to contest those determinations.

This consent expires 15 months after signed.

Name of Head of Household *
First Last
Date
MM / DD / YYYY
Head of Household Signature *
Clear
Spouse/Co-Head Signature
Clear
Other Family Member over 18 Signature
Clear
Other Family Member over 18 Signature
Clear
Other Family Member over 18 Signature
Clear
This authorization is made pursuant to the following:
Authority: 42 U.S.C 1437f and 3535 (d), implemented at 24CFR 982.551 (b)

Purpose: In signing this consent form, you are authorizing HUD and the above Housing Authority (HA) to request information detailed in the chart below. HUD and the HASA need this information to verify your eligibility for assisted housing benefits and to ensure that these benefits are set at the correct level. HUD and the HASA may participate in computer matching programs and use databases with these sources in order to verify your eligibility and level of benefits.
Information to be Verified and Potential Sources of Information: The information the HASA may verify and sources the HASA may contact with this authorization to release information includes the following:
Identity and relationship status; Courts and Post Offices; Criminal activity for background checks Law Enforcement Agencies; Previous landlords (including Housing Authorities / Agencies); Utility Companies; Past and Present Employers; Welfare Agencies; Child Support and Alimony Providers; Social Security Administration; Veteran’s Administration; State Unemployment Agencies; Retirement Systems; Banks and Other Financial Institutions for asset verification; Schools and Colleges for enrollment status, financial aid, and costs; Medical and Child Care Providers for Allowances
Who Must Sign the Consent Form: Each member of your household who is 18 years of age or older must sign the consent form. Additional signatures must be obtained from new adults members joining the household or whenever members of the household become 18 years of age.
Failure to Sign Consent Form: Your failure to sign the consent form may result in the denial or termination of rental assistance, and is subject to the HASA’s review and hearing procedures for Housing Choice Voucher (HCV) and Project Based Voucher (PBV) Programs.
Uses of Information to be Obtained: HUD is required to protect the information it obtains in accordance with the Privacy Act of 1974, 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 the HASA for the purpose of determining housing assistance. The HASA is also required to protect the information it obtains in accordance with any applicable State privacy law. HUD and HASA employees may be subject to penalties for unauthorized disclosures or improper uses of the information that is obtained based on the consent form.
Penalties for Misusing this Consent:
HUD, the HASA, and any owner (or any employee of HUD, the HASA or the owner) 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 this form is restricted to the purposes cited above. 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 disclosures of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the HASA or the owner responsible for the unauthorized disclosure or improper use.
Original form is retained by the Housing Authority of San Angelo
Email

This authorization is made pursuant to the following:

Information to be Verified and Potential Sources of Information: The information the HASA may verify and sources the HASA may contact with this authorization to release information includes the following:

Who Must Sign the Consent Form: Each member of your household who is 18 years of age or older must sign the consent form. Additional signatures must be obtained from new adults members joining the household or whenever members of the household become 18 years of age.

Original form is retained by the Housing Authority of San Angelo