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MicroE Consent & Release Form
COVID-19 Microenterprise Stabilization Program (MicroE)
Consent and Release Form, Nonpublic Personal Information
Form #5 For internal use
Date Rec’d ___/___/_____
Applicant/Business:
_______________________
Instructions: You must fill out this form (this “Consent”) in order to allow the Town of Bristol (“Bristol”) and Rhode
Island Office of Housing and Community Development (“OHCD”) to share non-public personal information (as
defined herein) regarding ________________________ (company name) (the “Applicant”) and any
principal/partner/owner of the Applicant with agencies and companies in order to process the application.
The Applicant and any principal/partner/owner of the Applicant may terminate this Consent at any time prior to
receipt of CDBG assistance. However, if the Applicant or any principal/partner/owner of the Applicant terminates this
Consent, the Town of Bristol will not be able to process your application and the Town of Bristol and/or OHCD will not
be able to provide CDBG assistance.
I/We, the undersigned individuals as principal/partner/owner of the Applicant, do hereby consent to and authorize the
Town of Bristol and OHCD (including its partners, affiliates, agents, contractors and their respective assigns), as part of
the Applicant’s application for Microenterprise Stabilization Program assistance (the “Program”), to request, access,
review, disclose, release and share any and all information received with respect to the Applicant’s application for the
Program (“Nonpublic Personal Information” or “NPI”), whether provided by the Applicant or any
principal/partner/owner of the Applicant, or by additional outside third parties with whom the Applicant or any of the
principals/partners/owners of the Applicant may or may not have a relationship, and only as necessary or desirable, in
the sole discretion of the Town of Bristol or OHCD, for final determination of the Applicant’s eligibility for and the
amount of assistance under the Program, and to comply with all applicable subsidy layering and duplication of benefits
requirements.
The Applicant and its principals/partners/owners of the Applicant authorize the release of all Nonpublic Personal
Information in order to comply with the Program eligibility and benefit determination requirements, and subsidy
layering and duplication of benefits requirements. The Applicant and the principals/partners/owners of the Applicant
understand and acknowledge that any party disclosing information on behalf of the Town of Bristol or OHCD, or to the
Town of Bristol or OHCD, on the behalf of the Applicant or any principal/partner/owner of the Applicant is not
responsible for any negligent misrepresentation or omission, and the Applicant and all of the undersigned agree to hold
the Town of Bristol, OHCD and such disclosing parties harmless from and against all claims, actions, suits or other
proceedings, and any and all losses, judgments, damages, expenses or other costs (including reasonable counsel fees
and disbursements), arising from or in any way relating to their disclosure.
As part of this Consent, the Applicant and all of the principals/partners/owners of the Applicant further authorize the
Town of Bristol and any other financial institution, lender, insurer, government agency (federal or state), credit bureau,
financial service provider or any other third party to obtain, use and disclose any of the NPI of the Applicant and/or any
principal/partner/owner of the Applicant in their possession, as necessary or desirable, in the sole discretion of the
Town of Bristol, to enable the Town of Bristol to administer the Program and process the Applicant’s application.
As part of this Consent, the Applicant and all of the principals/partners/owners of the Applicant further authorize
OHCD and any other financial institution, lender, insurer, government agency (federal or state), credit bureau, financial
service provider or any other third party to obtain, use and disclose any of the NPI of the Applicant and/or any
