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<br />Authorization for the Release of Information <br />PHA Requesting release of information: <br />County of Hawai`i <br />Office of Housing and Community Development <br />50 Wailuku Drive <br />Hilo, Hawai`i 96720 <br />808/961-8379 <br />Authority: 42 U.S.C. 1437f and 3535(d), implemented at 24 CFR Failure to Sign Consent Form: Your failure <br />982.551(b). to sign the consent form may result in the <br /> denial of eligibility or termination of <br /> assisted housing benefits, or both. Denial of <br />Purpose: In signing this consent form, you are authorizing HUD eligibility or termination of benefits is <br />and the above named HA to request information including but not subject to the HA’s grievance procedures. <br />limited: to identity and marital status, employment income, <br />welfare income, assets, residences and rental activity, Medical <br />or Child Care Allowances, Credit and Criminal Activity. HUD and Sources of Information: The groups or <br />the HA need this information to verify your eligibility for individuals that may be asked to release <br />assisted housing benefits and that these benefits are set at the information include but are not limited to: <br />correct level. HUD and the HA may participate in computer <br />matching programs with these sources in order to verify your <br />eligibility and level of benefits. <br />Uses of Information to be Obtained: HUD is required to protect the Previous Landlords (including PHAs) <br />information it obtains in accordance with the Privacy Act or 1974, Courts and Post Offices <br />5 U.S.C. 552a. HUD may disclose information (other than tax return Schools and Colleges <br />information) for certain routine uses, such as to other government Law Enforcement Agencies <br />agencies for law enforcement purposes, to Federal agencies for Support and Alimony Providers <br />employment suitability purposes and to HAs for the purpose of Past and Present Employers <br />determining housing assistance. The HA is also required to protect Welfare Agencies <br />the information it obtains in accordance with any applicable State State Unemployment Agencies <br />privacy law. HUD and HA employees may be subject to penalties for Social Security Administration <br />unauthorized disclosures or improper uses of the information that is Medical and Child Care Providers <br />obtained based on the consent form. Veterans Administration <br /> Retirement Systems <br />Who Must Sign the Consent Form: Each member of your household who Banks and other Financial <br />Institution <br />is 18 years of age or older must sign the consent form. Additional Credit Providers and Credit Bureaus <br />signatures must be obtained from new adult members joining the Utility Companies <br />household or whenever members of the household become 18 years of age. <br />Consent: I consent to allow HUD or the HA to request and obtain any information from any Federal, State or <br />local agency, organization, business, or individual for the purpose of verifying my eligibility and level of <br />benefits under HUD’s assisted housing programs. I understand that HAs that receive information under this <br />consent form cannot use it to deny, reduce or terminate assistance without first independently verifying the <br />information obtained. In addition, I must be given an opportunity to contest those determinations. <br />This consent form expires 15 months after signed. <br />Signatures: <br />________________________________ _________________ __________________________________ ____________ <br />Head of Household Date Other Family Member over age 18 Date <br />________________________________ _________________ __________________________________ ____________ <br />Spouse Date Other Family Member over age 18 Date <br />________________________________ _________________ __________________________________ ____________ <br />Other Family Member over age 18 Date Other Family Member over age 18 Date <br />Penalties for Misusing this Consent: <br />HUD, the HA and any owner (or any employee of HUD, the HA or the owner) may be subject to penalties for <br />unauthorized disclosures or improper uses of information collected based on the consent form. Use of the <br />information collected based on this form is restricted to the purposes cited above. Any person who knowingly <br />or willfully request, obtains or discloses any information under false pretenses concerning an applicant or <br />participant may be subject to a misdemeanor and fined not more that $5,000. Any applicant or participant <br />affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as <br />may be appropriate, against the officer or employee of HUD, the HA or the owner responsible for the <br />unauthorized disclosure or improper use. <br />2/2004 Original is retained by the requesting organization. <br />6238rbla <br /> <br />