Authorization for the Release of Information/
Privacy Act Notice
to the U.S. Department of Housing and Urban Development (HUD)
and the Housing Agency/Authority (HA)
P
HA requesting release of information: (Cross out space if none) IHA requesting release of information: (Cross out space if none)
(Full address, name of contact person, and date) (Full address, name of contact person, and date)
City of West Allis Department of Development
Housing Division
7525 West Greenfield Avenue
West Allis, WI 53214
Authority: Section 904 of the Stewart B. McKinney Homeless
Assistance Amendments Act of 1988, as amended by Section
903 of the Housing and Community Development Act of 1992
and Section 3003 of the Omnibus Budget Reconciliation Act of
1993. This law is found at 42 U.S.C. 3544.
This law requires that you sign a consent form authorizing: (1)
HUD and the Housing Agency/Authority (HA) to request
verification of salary and wages from current or previous
employers; (2) HUD and the HA to request wage and
unemployment compensation claim information from the state
agency responsible for keeping that information; (3) HUD to
request certain tax return information from the U.S. Social
Security Administration and the U.S. Internal Revenue Service.
The law also requires independent verification of income
information. Therefore, HUD or the HA may request
information from financial institutions to verify your eligibility
and level of benefits.
Purpose: In signing this consent form, your are authorizing
HUD and the above-named HA to request income information
from the sources listed on the form. HUD and the HA need
this information to verify your household’s income, in order to
ensure that you are eligible for assisted housing benefits and
that these benefits are set at the correct level. HUD and the
HA may participate in computer matching programs with these
sources in order to verify your eligibility and level of benefits.
Uses of Information to be Obtained: HUD is required to
protect the income information it obtains in accordance with the
Privacy Act of 1974, 5 U.S.C. 522a. 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 HA’s for the purpose of determining
housing assistance. The HA is also required to protect the
income information it obtains in accordance with any applicable
State privacy law. HUD and HA employees may be subject to
penalties for unauthorized disclosures improper uses of the
income information that is obtained based on the consent form.
Private owners may not request or receive information
authorized by this form.
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
adult members joining the household or whenever members of the
household become 18 years of age.
O
riginal is retained by the requesting organization
Persons who apply for or receive assistance under the
following programs are required to sign this consent form:
PHA-owned rental public housing
Turnkey III Homeownership Opportunities
Mutual Help Homeownership Opportunities
Section 23 and 19(c) leased housing
Section 23 Housing Assistance Payments
HA-owned rental Indian Housing
Section 8 Rental Certificate
Section 8 Rental Voucher
Section 8 Moderate Rehabilitation
Failure to Sign Consent Form: Your failure to sign the
consent form may result in the denial of eligibility or termination
of assisted housing benefits, or both. Denial of eligibility or
termination of benefits is subject to the HA’s grievance
procedures and Section 8 informal hearing procedures.
Sources of Information To Be Obtained
State Wage information Collection Agencies. (This consent is
limited to wages and unemployment compensation I have
received during period(s) within the last 5 years when I have
received assisted housing benefits.)
U.S. Social Security Administration (HUD only) (This consent
is limited to unearned income {i.e., interest and dividends).
Information may also be obtained directly from: (a) current and
former employers concerning salary and wages and (b)
financial institutions concerning unearned income (i.e. interest
and dividends). I understand that income information obtained
from these sources will be used to verify information that I
provide in determining eligibility for assisted housing programs
and the level of benefits. Therefore, this consent form only
authorizes release directly from employers and financial
institutions of information regarding any period(s) within the
last 5 years when I have received assisted housing benefits.
Ref. Handbooks 7420.7, 7420.8 & 7465.1 form HUD-9886 (7/94)
U.S. Department of Housing and
Urban Development
Office of Public and Indian Housing