2160 41
st
Avenue, California, 95010-2040 Telephone: (831) 454-9455, Hollister: (831) 637-0487
Fax: (831) 469-3712, TDD (831) 475-1146
www.hacosantacruz.org
AUTHORIZATION TO RELEASE INFORMATION
I/We hereby give my/our consent to have the Housing Authority of the County of Santa Cruz obtain any and all
information deemed necessary to determine or redetermine my/our eligibility for housing assistance. Therefore,
I/we authorize the release of any of the information described below, as requested by the Housing Authority of the
County of Santa Cruz.
I/We understand that this release of information includes the collection of information regarding my/our
employment, Unemployment Insurance Benefits, any and all other benefits, child support and spousal support,
bank accounts, any other income, asset or household information. Additionally, I/we give my/our consent to have
the Housing Authority verify any childcare expenses, medical expenses, disability assistance expenses, full time
student status and disability status, and criminal history.
I/we understand that this information may be disclosed to local public agencies and law enforcement for the
purposes of ensuring program integrity and to prevent the misuse of public funds.
I/we understand that this information will be kept confidential and is being requested for the purpose of
determining my/our eligibility for housing assistance.
I also authorize this form to be photocopied and used as an original.
ALL HOUSEHOLD MEMBERS 18 YEARS OR OLDER MUST SIGN.
This consent form expires 3 years following the end of program participation
______________________________ _________________________________________________________
Print Name Signature Date
______________________________ _________________________________________________________
Print Name Signature Date
______________________________ _________________________________________________________
Print Name Signature Date
______________________________ _________________________________________________________
Print Name Signature Date
050336 122016 BA
