Authorization for the Release of Information / Privacy Act Notice
◆◆
◆◆
◆ Alternative to Form HUD-9886
◆◆
◆◆
◆
Federal law (42 U.S.C. § 3544) and U.S. Department of Housing and Urban Development (HUD) regulation (24 CFR § 5.230) require
that
you and all authorized family members 18 years of age and older must sign a consent form such as this form. Failure to
sign this consent form may result in denial of eligibility and / or termination of tenancy or subsidy. This consent authorizes
NYCHA (deemed to include NYCHA’s private managers) and HUD to get information directly from third party sources in order to verify
the income, the value of assets, expenses related to deductions from income (including medical and day care expenses), family
composition and related information for every household member. The information received is used by NYCHA and HUD for the
purposes of determining that your family is eligible for public housing/Section 8 benefits and that these benefits are set at the right level.
In order to complete or verify an application for participation and to maintain continued assistance in public housing or a
Section 8 program, this consent form authorizes the release of information necessary to permit:
(1) HUD and NYCHA to obtain information from SWICAs (State Wage Information Collection Agencies - e.g., a Labor Dept.).
(2) HUD and NYCHA to obtain: (a) salary and wage income information from previous or current employers; and (b) unearned income
(i.e., interest and dividend) information from banks or other financial institutions.
(3) HUD and NYCHA to obtain information such as but not limited to: public or private pension funds, unemployment compensation
information, worker’s compensation, disability income, military pay, alimony, child support, private contributions, school attendance
verification and information relating to the receipt of financial grants, from various entities, credit agencies or government agencies,
including but not limited to the:
z
NYC Human Resources Administration,
z
NYC Office of Payroll Administration,
z
NYC Department
of Finance,
z
NYC Department of Health and Mental Hygiene,
z
NYC Clerk’s Office,
z
NYS Department of Motor Vehicles,
z
Courts and NYS Office of Court Administration,
z
NYS Department of Labor and
z
US Department of Veterans Affairs.
(4) HUD and NYCHA to obtain information from the Social Security Administration (SSA) for the purpose of disclosure and verification
of Social Security Numbers and verification of income information so as to determine an individual’s eligibility or level of benefits.
(5) HUD to obtain taxpayer return information from the Internal Revenue Service (IRS).
CONSENT: I consent to allow HUD or NYCHA 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 based on the information received under this
consent form, NYCHA cannot use it to deny, reduce or terminate assistance without first independently verifying what the amount was, and if and
when the funds were received. In addition, I must be given an opportunity to contest those determinations.
Privacy Act Notice.
Authority: 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 of age or older.
Purpose: Your income and other information are being collected by HUD and NYCHA to determine your eligibility, the appropriate bedroom size, and the
amount your family will pay toward rent and utilities.
Other Uses: HUD uses your family income and other information to assist in managing and monitoring
HUD-assisted housing programs, to protect the Government’s financial interest, and to verify the accuracy of the information you provide. This information
may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatory investigators and prosecutors. However,
the information will not be otherwise disclosed or released outside of HUD or NYCHA, except as permitted or required by law.
Penalty: You must provide all
of the information requested by NYCHA, including all Social Security Numbers you, and all other household members age six years and older, have and use.
Giving the Social Security Numbers of all household members six years of age and older is mandatory, and not providing the Social Security Numbers will
affect your eligibility. Failure to provide any of the requested information may result in a delay or rejection of your eligibility approval.
NEW YORK CITY HOUSING
AUTHORITY (NYCHA)
NYCHA 040.608 (Rev. 11/04)
THIRD PARTY VERIFICATION -
Consent to Release Information
NYCHA DEVELOPMENT
Head of
Household:
Spouse:
1
2
3
4
5
6
7
Print Name
Family Members Age 18 or Older
Date of
Birth
Social Security
Number
Sign Name
Date
TENANT/APPLICANT STREET ADDRESS:
APT. NO.:
BOROUGH:
NYCHA ACCOUNT # / § 8 VOUCHER #:
, New York ZIP:
Photocopies of this consent form shall be valid as the original. The authorization to release information
contained in this consent form expires 15 months after the date on which this consent form is signed.
AA
