Fillable Homeowner Assistance Program (HoAP) FORM B (City of Houston)

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Homeowner Assistance Program (HoAP) FORM B (City of Houston)

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Page 1 of 2
Form B HoAP Communication Designee
Version 1.3 March 2020
Homeowner Assistance Program (HoAP) FORM B
Communication Designee (Permission to Applicant Information)
Applicant Name: Application ID #:
Co-Applicant Name:
(If Applicable)
Damaged Property:
Instructions: Applicants to the Homeowner Assistance Program (HoAP) can designate a third party to obtain information about
their HoAP application. This third party is known as the Communication Designee and they will be authorized to make inquiries
of the applicant’s program status by the methods of delivery selected below. The person or agency designated as the
Communication Designee is not authorized to sign the grant agreement or any other documents or affidavits on behalf of the
applicant unless they also hold a valid Power of Attorney (POA). Applicants may designate an individual or an agency as a
Communication Designee. If you are using this form authorizing permission to a new Communication Designee to access
applicant information surrounding your HoAP Application, please complete Sections 1 and 2. If you are revoking permission
previously granted to a person or agency or Communication Designee, please complete Sections 1 and 3. If you wish to
authorize or revoke multiple Communication Designees, separate forms should be completed for each designee.
SECTION 1: Information to Access Applicant Information
I do hereby authorize the City of Houston, Texas, Housing Community Development Department (HCDD) Disaster Recovery
Division, and/or their affiliates* to share the following specific information with:
Who can access my information:
For example: Jane Doe OR ABC Elevation Services
Name: ______________________________________________
Agency, if applicable: __________________________________
Relationship with this person/agency: Family or Close Friend
Attorney, CPA, or Similar Professional
Builder/Contractor
Non-Profit or Long-Term Recovery Group
Other:
Address and phone number of person/agency (and
agency representative name):
For example: 123 ABC Street, Agency Rep Name
Houston, TX 77025
(830) 555-1234
Address: __________________________________________
__________________________________________
Telephone: __________________________________________
Email: __________________________________________
What information may be disclosed
(select all that apply):
Please note: Specific payment-related inquiries will
not be shared with builders/contractors.
Contractor Validation Requirements
Environmental and Asbestos/Lead Inquiries
Payment Requirements
Scope of Work Inquiries
All Documents
Other: ____________________________
Method(s) of delivery:
By phone By e-mail** In-person meeting
** By selecting this option, you understand that electronic correspondence
may not be confidential and may be intercepted and read by other people.
PIN/Password:
Required to access application information
PIN/Password: ________________________________________
This permission will expire on:
For example: 08/10/2018
Expiration Date: _______________________________________
*Affiliates may include the City of Houston’s contractors, subcontractors, consultants; and partner non-profit or volunteer organizations.
Page 2 of 2
Form B HoAP Communication Designee
Version 1.3 March 2020
Application ID #: _____________________
SECTION 2: Applicant’s Certification (Authorizing) Communication Designee
Instructions: Complete Section 2 ONLY if you are authorizing a new Communication Designee. Applicant and Co-Applicant (If
Applicable) must complete the Certification below.
1. I/We certify that I/we are the owner of the home located at the above-referenced address.
2. I/We understand and acknowledge that I/we do not have to sign a release form, however am hereby doing so freely
and voluntarily.
3. I/We understand and acknowledge that I/we do not have to allow any Person/Agency access to information related
to my/our HoAP Application.
4. I/We understand that this form authorizes and permits the City of Houston, Texas, Housing and Communit
y
De
velopment Department (HCDD) Disaster Recovery Division, and their affiliates to disclose and share
information with the Communication Designee.
5. I/We must sign a new HoAP Communication Designee form for each person or agency to whom I/we wish to extend
access to and receive information about my/our HoAP application from the City of Houston, Texas Housing and
Community Development Department and/or its affiliates.
6. I/We understand that I/we can revoke this permission at any time by filling out a HoAP Communication Designee
form to revoke this permission and returning it to my/our Housing Advisor or Housing Recovery Center.
Warning: Any person who knowingly makes a false claim or statement to HUD may be subject to civil or criminal penalties
under 18 U.S.C. 287, 1001 and 31 U.S.C. 3729. Under penalties of perjury, I/we certify that the information presented above
is true and accurate to the best of my/our knowledge and belief. I/We further understand that providing false
representations herein constitutes an act of fraud. False, misleading or incomplete information may result in my
ineligibility to participate in this program or any other programs that will accept this document. Title 18, Section 1001 of the
U.S. Code states that a person is guilty of a FELONY if he/she knowingly and willfully makes a false statement to any
department of the United States Government.
Signature - Applicant
Date
SECTION 3: Applicant’s Certification (Revoking) Communication Designee
Instructions: Complete Section 3 ONLY if you are revoking a previously assigned Communication Designee. Applicant and Co-
Applicant (If Applicable) must complete the Certification below.
1. I/We certify that I/we are the owner of the home located at the above-referenced address.
2. I/We hereby revoke permission for the above-referenced Communication Designee to access my/our HoAP
application information.
Warning: Any person who knowingly makes a false claim or statement to HUD may be subject to civil or criminal penalties
under 18 U.S.C. 287, 1001 and 31 U.S.C. 3729. Under penalties of perjury, I/we certify that the information presented above is
true and accurate to the best of my/our knowledge and belief. I/We further understand that providing false representations
herein constitutes an act of fraud. False, misleading or incomplete information may result in my ineligibility to participate
in this program or any other programs that will accept this document. Title 18, Section 1001 of the U.S. Code states that a
person is guilty of a FELONY if he/she knowingly and willfully makes a false statement to any department of the United States
Government.
Signature - Applicant
Signature - Co-Applicant
Date
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Homeowner Assistance Program (HoAP) FORM B (City of Houston)

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Completed 21 December 2020

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