060102 05/17/16 ls
Head of Household Name: ________________________________ Last 4 digits of SS#: ______________
I authorize the following person or agency: Name: __________________________________________
(if individual signing for the agency, any agency representative is authorized)
Relationship to Head of Household:________________________________ Phone:___________________
Agency (if applicable):___________________________
Street Address: ______________________________________________________________________________________
City: ________________________________ State: ________________________ Zip Code: _______________
Complete Mailing Address (if different): _______________________________________________________________
To (Head of Household must initial all that apply):
_____ Receive all correspondence from the Housing Authority (instead of having it sent to me.)
I am responsible for notifying the Housing Authority in writing of changes to the Authorized Person’s address
Discuss any matters relating to me with Housing Authority staff.
The Housing Authority is authorized to share any information they may have about me, members of my
household, or my status in the Section 8 program with the Authorized Person.
State Reason for Request:
It is my responsibility to communicate with the Authorized Person or Agency about information he or she has submitted
to or otherwise, shared with the Housing Authority on my behalf. I (the head of household) understand that this
agreement does not release me from my responsibility to comply with all program requirements.
Nothing in this agreement prevents me (the head of household) from acting on my own behalf. I understand that I may
call the Housing Authority directly and respond directly to correspondence. This agreement will not expire unless I
notify the Housing Authority in writing that I would like to cancel it. This agreement is not effective unless the
Housing Authority approves it by signing below.
______________________________________ ______________
Head of Household’s Signature Date
______________________________________ ______________________________ _________
Authorized Person Signature
Authorized Person Name (Print or Type) Date
The Housing Authority will inform you of the granting, denial or status of this request within thirty (30) days of the
receipt of this request.
___________________________________________ _________________________
Housing Authority
Authorization Date
If you have any questions regarding this form, please contact the Housing Authority at (831) 454-9455 Monday through
Thursday, between 8:00 AM – 4:30 PM.
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