Fill - Free fillable Verification Info Applicants 9887 (Commonwealth of Massachusetts) PDF form

U.S. Department of Housing and Urban Development

Document Package for

Applicant's/Tenant's Consent

to the

Release Of Information

This Package contains the following documents:

1.HUD-9887/A Fact Sheet describing the necessary verifications

2.Form HUD-9887 (to be signed by the Applicant or Tenant)

3.Form HUD-9887-A (to be signed by the Applicant or Tenant and Housing Owner)

4.Relevant Verifications (to be signed by the Applicant or Tenant)

Each household must receive a copy of the 9887/A Fact Sheet, form HUD-9887, and form HUD-9887-A.

Attachment to forms HUD-9887 & 9887-A (02/2007)

HUD-9887/A Fact Sheet

Verification of Information Provided by

Applicants and Tenants of Assisted Housing

What Verification Involves

To receive housing assistance, applicants and tenants who are at least 18

years of age and each family head, spouse, or co-head regardless of age

must provide the owner or management agent (O/A) or public housing agency

(PHA) with certain information specified by the U.S. Department of Housing

and Urban Development (HUD).

To make sure that the assistance is used properly, Federal laws require

that the information you provide be verified. This information is verified in two

ways:

1. HUD, O/As, and PHAs may verify the information you provide by

checking with the records kept by certain public agencies (e.g.,

Social Security Administration (SSA), State agency that keeps wage

and unemployment compensation claim information, and the

Department of Health and Human Services’ (HHS) National Directory

of New Hires (NDNH) database that stores wage, new hires, and

unemployment compensation). HUD (only) may verify information

covered in your tax returns from the U.S. Internal Revenue Service

(IRS). You give your consent to the release of this information by

signing form HUD-9887. Only HUD, O/As, and PHAs can receive

information authorized by this form.

2. The O/A must verify the information that is used to determine your

eligibility and the amount of rent you pay. You give your consent to the

release of this information by signing the form HUD-9887, the form

HUD-9887-A, and the individual verification and consent forms that

apply to you. Federal laws limit the kinds of information the O/A can

receive about you. The amount of income you receive helps to

determine the amount of rent you will pay. The O/A will verify all of the

sources of income that you report. There are certain allowances that

reduce the income used in determining tenant rents.

Example: Mrs. Anderson is 62 years old. Her age qualifies her for a

medical allowance. Her annual income will be adjusted because of

this allowance. Because Mrs. Anderson’s medical expenses will

help determine the amount of rent she pays, the O/A is required to

verify any medical expenses that she reports.

Example: Mr. Harris does not qualify for the medical allowance

because he is not at least 62 years of age and he is not

handicapped or disabled. Because he is not eligible for the medical

allowance, the amount of his medical expenses does not change

the amount of rent he pays. Therefore, the O/A cannot ask Mr.

Harris anything about his medical expenses and cannot verify with

a third party about any medical expenses he has.

Customer Protections

Information received by HUD is protected by the Federal Privacy Act.

Information received by the O/A or the PHA is subject to State privacy

laws. Employees of HUD, the O/A, and the PHA are subject to

penalties for using these consent forms improperly. You do not have to

sign the form HUD-9887, the form HUD-9887-A, or the individual

verification consent forms when they are given to you at your

certification or recertification interview. You may take them home with

you to read or to discuss with a third party of your choice. The O/A will

give you another date when you can return to sign these forms.

If you cannot read and/or sign a consent form due to a disability, the

O/A shall make a reasonable accommodation in accordance with

Section 504 of the Rehabilitation Act of 1973. Such accommodations

may include: home visits when the applicant's or tenant's disability

prevents him/her from coming to the office to complete the forms; the

applicant or tenant authorizing another person to sign on his/her

behalf; and for persons with visual impairments, accommodations may

include providing the forms in large script or braille or providing

readers.

If an adult member of your household, due to e

tenuating circumstances, is

unable to sign the form HUD-9887 or the individual verification forms on time,

the O/A may document the file as to the reason for the delay and the specific

plans to obtain the proper signature as soon as possible.

The O/A must tell you, or a third party which you choose, of the

findings made

as a result of

the O/A verifications authorized by your

consent. The O/A must give you the opportunity to contest such

findings in accordance with HUD Handbook 4350.3 Rev. 1. However, for

information received under the form HUD-9887 or form HUD-9887-A, HUD, the

O/A, or the PHA, may inform you of these findings.

O/As must keep tenant files in a location that ensures confidentiality.

employee of the O/A who fails to keep tenant information

confidential is subject to the enforcement provisions of the State Privacy Act

and is subject to enforcement actions by HUD. Also, any applicant or tenant

affected by negligent disclosure or improper use of information may bring civil

action for damages, and seek other relief, as may be appropriate, against the

employee.

HUD-9887/A requires the O/A to give each household a copy of the Fact

Sheet, and form

s HUD-9887, H

UD-9887-A along with appropriate individual

consent forms. The package you will receive will include the

following documents:

1.HUD-9887/A Fact

Sheet:

Describes the requirement to verify

information provided by individuals who apply for housing assistance. This

fact sheet also describes consumer protections under the verification

process.

2.Form HUD-9

887: Allow

the release of information between

government agencies.

3.Form HUD-9

887-A: Describ

es the requirement of third part

verification along with consumer protections.

4.Individual v

erification consents: Used to

verif

y the relevant

information provided by applicants/tenants to determine their eligibility and

level of benefits.

Consequences for Not Signing the Consent Forms

If you fail to sign the form HUD-9887, the form HUD-9887-A, or the

individual verification forms, this

may result in your assistance being

denied (for applicants) or your assistance being terminated (for tenants). See

further explanation on the forms HUD-9887 and 9887-A.

If you are an applicant and are denied assistance for this reason, the O/A

must notif

you of the reason for your rejection and give you an

opportunity to appeal the decision.

If you are a tenant and your assistance is terminated for this reason,

the O/A must follow the proce

dures set out in the Lease. This includes

the opportunity for you to meet with the O/A.

Programs Covered by this Fact Sheet

Rental Assistance Program

(RAP)

Rent Supplement

Section 8 Housing Assistance Payments Programs (administered by the

Office of Housing)

Section 202

Sections 202 and 811 PRAC

Section 202/162 PAC

Section 221(d)(3) Below Market Interest Rate

Section 236

HOPE 2 Home Ownership of Multifamily Units

O/As must give a copy of this HUD Fact Sheet to each household. See the Instructions on form HUD-9887-A.

Attachment to forms HUD-9887 & 9887-A (02/2007)

Notice and Consent for the Release of Information

to the U.S. Department of Housing and Urban Development (HUD) and to

an Owner and Management Agent (O/A), and to a Public Housing

Agency (PHA)

U.S. Department of Housing

and Urban Development

Office of Housing

Federal Housing Commissioner

HUD Office requesting release of information

(Owner should provide the full address of the

HUD Field Office, Attention: Director, Multifamily

Division.):

O/A requesting release of

information (Owner should provide the full

name and address of the Owner.):

PHA requesting release of information (Owner should

provide the full name and address of the PHA and the title of

the director or administrator. If there is no PHA Owner or

PHA contract administrator for this project, mark an X

through this entire box.):

NoticeToTenant:Donotsignthisformifthespaceabovefororganizationsrequestingreleaseofinformationisleftblank.Youdonothavetosign

thisformwhenitisgiventoyou.Youmaytaketheformhomewithyoutoreadordiscusswithathirdpartyofyourchoiceandreturntosignthe

consentonadateyouhaveworkedoutwiththehousingowner/manager.

Authority: Section 217 of the Consolidated Appropriations Act of 2004

(Pub L. 108-199). This law is found at 42 U.S.C.653(J). This law authorizes

HHS to disclose to the Department of Housing and Urban Development

(HUD) information in the NDNH portion of the “Location and Collection

System of Records” for the purposes of verifying employment and income of

individuals participating in specified programs and, after removal of personal

identifiers, to conduct analyses of the employment and income reporting of

these individuals. Information may be disclosed by the Secretary of HUD to a

private owner, a management agent, and a contract administrator in the

administration of rental housing assistance.

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 you to sign a consent form authorizing: (1) HUD and the PHA to

request wage and unemployment compensation claim information from the

state agency responsible for keeping that information; and (2) HUD, O/A, and

the PHA responsible for determining eligibility to verity salary and wage

information pertinent to the applicant’s or participant’s eligibility or level of

benefits; (3) HUD to request certain tax return information from the U.S.

Social Security Administration (SSA) and the U.S. Inte

rnal Revenue Service (IRS).

Purpose: In signing this consent form, you are authorizing HUD, the above-

named O/A, and the PHA to request income information from the government

agencies listed on the form. HUD, the O/A, and the PHA need this

information to verify your household’s income to ensure that you are eligible

for assisted housing benefits and that these benefits are set at the correct

level. HUD, the O/A, and the PHA may participate in computer matching

programs with these sources to verify your eligibility and level of benefits.

This form also authorizes HUD, the O/A, and th

e PHA to seek wage, new hire

(W-4), and unemployment claim information from current or former employers

to verify information obtained through computer matching.

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. 552a. The O/A and the PHA is also required to protect the income

information it obtains in accordance with an

y applicable State privacy law.

After receiving the information covered by this notice of consent, HUD, the

O/A, and the PHA may inform you that your eligibility for, or level of, assistance

is uncertain and needs to be verified and nothing else.

HUD, O/A, and PHA employees may be subject t

o penalties for unauthorized

disclosures or improper uses of the income information that is obtained based

on the consent form.

Who Must Sign the Consent Form: Each m

ember of your household who

at least 18 years of age and each family head, spouse or co-head, regardless of

age, must sign the consent form at the initial certification

and at each

recertification. Additional signatures must be obtained from new adult

members when they join the household or when members of the household

become 18 years of age.

Persons who apply for or receive assistance under the following programs are

required to sign this consent form:

Rental Assistance Program (RAP)

Rent Supplement

Section 8 Housing Assistance Payments Programs (administered by the

Office of Housing)

Section 202; Sections 202 and 811 PRAC; Section 202/162 PAC Section

221(d)(3) Below Market Interest Rate

Section 236

HOPE 2 Homeownership of Multifamily Units

FailuretoSignConsentForm:Y

our failure to sign the consent form may

result in the denial of assistance or termination of assisted housing benefits. If

an applicant is denied assistance for this reason, the owner must follow the

notification procedures inHandbook 4350.3 Rev. 1. If a tenant is denied

assistance for this reason, the owner or managing agent must follow the

procedures set out in the lease.

________________________________________________________________________________________________________________________________

Consent:IconsenttoallowHUD,theO/A,orthePHAtorequestandobtainincomeinformationfromthefederalandstateagencies

listedonthebackofthisformforthepurposeofverifyingmyeligibilityandlevelofbenefitsunderHUD'sassistedhousingprograms.

Signatures: Additional Signatures, if needed:

Head of Household Date Other Family Members 18 and Over Date

Spouse Date Other Family Members 18 and Over Date

Other Family Members 18 and Over Date Other Family Members 18 and Over Date

Original is retained on file at the project site ref. Handbooks 4350.3 Rev-1, 4571.1, 4571/2 & form HUD-9887 (02/2007)

4571.3 and HOPE II Notice of Program Guidelines

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

Agencies To Provide Information

State Wage Information Collection Agencies. (HUD and

PHA). This consent is limited to wages and unemployment

compensation you have received during period(s) within the last 5

years when you have received assisted housing benefits.

U.S. Social Security Administration (HUD only). This consent is

limited to the wage and self employment information from your

current form W-2.

National Directory of New Hires contained in the Department of

Health and Human Services’ system of records. This consent is

limited to wages and unemployment compensation you have

received during period(s) within the last 5 years when you have

received assisted housing benefits.

U.S. Internal Revenue Service (HUD only). This consent is limited

to information covered in your current tax return.

This consent is limited to the following information that may

appear on your current tax return:

1099-S Statement for Recipients of Proceeds from Real Estate

Transactions

1099-B Statement for Recipients of Proceeds from Real Estate

Brokers and Barters Exchange Transactions

1099-A Information Return for Acquisition or Abandonment of

Secured Property

1099-G Statement for Recipients of Certain Government

Payments

1099-DIV Statement for Recipients of Dividends and Distributions

1099 INT Statement for Recipients of Interest Income

1099-MISC Statement for Recipients of Miscellaneous

Income

1099-OID Statement for Recipients of Original Issue Discount

1099-PATR Statement for Recipients of Taxable Distributions

Received from Cooperatives

1099-R Statement for Recipients of Retirement Plans W2-G

Statement of Gambling Winnings

1065-K1 Partners Share of Income, Credits, Deductions,

etc.

1041-K1 Beneficiary’s Share of Income, Credits, Deductions, etc.

1120S-K1 Shareholder’s Share of Undistributed Taxable Income,

Credits, Deductions, etc.

I understand that income information obtained from these sources

ill be used to verify information that I provide in determining initial

or continued eligibility for assisted housing programs and the level

of benefits.

No action can be taken to terminate, deny, suspend, or reduce the

assistanc

e your household receives based on information obtained

about you under this consent until the HUD Office, Office of

Inspector General (OIG) or the PHA (whichever is applicable) and

the O/A have independently verified: 1) the amount of the income,

wages, or unemployment compensation involved, 2) whether you

actually have (or had) access to such income, wages, or benefits

for your own use, and 3) the period or periods when, or with

respect to which you actually received such income, wages, or

benefits. A photocopy of the signed consent may be used to

request a third party to verify any information received under this

consent (e.g., employer).

HUD, the O/A, or the PHA shall inform you, or

a third party which

you designate, of the findings made on the basis of information

verified under this consent and shall give you an opportunity to

contest such findings in accordance with Handbook 4350.3 Rev. 1.

If a member of the household who is required to sign the consent

form is un

able to sign the form on time due to extenuating

circumstances, the O/A may document the file as to the reason for

the delay and the specific plans to obtain the proper signature as

soon as possible.

This consent form expires 15 months after signed.

Privacy Act Statement. The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S.

Housing Act of 1937, as amended (42 U.S.C. 1437 et. seq.); the Housing and Urban-Rural Recovery Act of 1983 (P.L. 98-181); the Housing

and Community Development Technical Amendments of 1984 (P.L. 98-479); and by the Housing and Community Development Act of 1987

(42 U.S.C. 3543). The information is being collected by HUD to determine an applicant’s eligibility, the recommended unit size, and the

amount the tenant(s) must pay toward rent and utilities. HUD uses this information to assist in managing certain HUD properties, to protect

the Government’s financial interest, and to verify the accuracy of the information furnished. HUD, the owner or management agent (O/A), or

a public housing agency (PHA) may conduct a computer match to verify 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, except as permitted or required by law. You must provide all of

the information requested. Failure to provide any information may result in a delay or rejection of your eligibility approval.

Penalties for Misusing this Consent:

HUD, the O/A, and any PHA (or any employee of HUD, the O/A, or the PHA) may be subject to penalties for unauthorized disclosures or

improper uses of information collected based on the consent form.

Use of the information collected based on the form HUD 9887 is restricted to the purposes cited on the form HUD 9887. Any person who

knowingly or willfully requests, obtains, or discloses any information under false pretenses concerning an applicant or tenant may be subject

to a misdemeanor and fined not more than $5,000.

Any applicant or tenant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be

appropriate, against the officer or employee of HUD, the Owner or the PHA responsible for the unauthorized disclosure or improper use.

Original is retained on file at the project site ref. Handbooks 4350.3 Rev-1, 4571.1, 4571.2 & form HUD-9887 (02/2007)

4571.3 and HOPE II Notice of Program Guidelines

Applicant's/Tenant's Consent to the

Release of Information

Verification by Owners of Information

Supplied by Individuals Who Apply for Housing Assistance

Instructions to Owners

U.S. Department of Housing

and Urban Development

Office of Housing

Federal Housing Commissioner

1. Give the documents listed below to the applicants/tenants to sign.

Staple or clip them together in one package in the order listed.

a. The HUD-9887/A Fact Sheet.

b. Form HUD-9887.

c. Form HUD-9887-A.

d . Relevant verifications (HUD Handbook 4350.3 Rev. 1).

2. Verbally inform applicants and tenants that

a. They may take these forms home with them to read or to

discuss with a third party of their choice and to return to sign

them on a date they have worked out with you, and

b. If they have a disability that prevents them from reading and/

or signing any consent, that you, the Owner, are required to

provide reasonable accommodations.

3. Owners are required to give each household a copy of the

HUD9887/A Fact Sheet, form HUD-9887, and form HUD-9887-A

after obtaining the required applicants/tenants signature(s). Also,

owners must give the applicants/tenants a copy of the signed

individual verification forms upon their request.

Instructions to Applicants and Tenants

This Form HUD-9887-A contains customer information and

protections concerning the HUD-required verifications that Owners

must perform.

1. Read this material which explains:

• HUD’s requirements concerning the release of information,

and

• Other customer protections.

2. Sign on the last page that:

• you have read this form, or

• the Owner or a third party of your choice has explained it to you,

and

• you consent to the release of information for the purposes and

uses described.

Authority for Re

quiring Applicant's/Tenant's Consent to the

Release of Information

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. This law is found at 42 U.S.C.

3544.

In part, this law requires you to sign a consent form authorizing the

Owner to

request current or previous employers to verify salary and wage

information pertinent to your eligibility or level of benefits.

In addition, HUD regulations (24 CFR 5.659, Family Information and

Verification) require as a condition of receiving housing assistance that

you must sign a HUD-approved release and consent authorizing any

depository or private source of income to furnish such information that is

necessary in determining your eligibility or level of benefits. This includes

Purpose of Requiring Consent to the Release of Information

In signing this consent form, you are a

uthorizing the Owner of the

housing project to which you are applying for assistance to request

information from a third party about you. HUD requires the housing

owner to verify all of the information you provide that affects your

eligibility and level of benefits to ensure that you are eligible for

assisted housing benefits and that these benefits are set at the

correct levels. Upon the request of the HUD office or the PHA (as

Contract Administrator), the housing Owner may provide HUD or the

PHA with the information you have submitted and the information

the Owner receives under this consent.

Uses of Information to be Obtained

The individual listed on the verification form may request and

receiv

e the information requested by the verification, subject to the

limitations of this form. HUD is required to protect the income

information it obtains in accordance with the Privacy Act of 1974, 5

U.S.C. 552a. The Owner and the PHA are also required to protect

the income information they obtain in accordance with any

applicable state privacy law. Should the Owner receive information

from a third party that is inconsistent with the information you have

provided, the Owner is required to notify you in writing identifying the

information believed to be incorrect. If this should occur, you will

have the opportunity to meet with the Owner to discuss any

discrepancies.

Who Must Sign the Consent Form

Each member of your household who is at least 18 years of age, and

each family head, spouse or co-head, regardless of age

must sign the

relevant consent forms at the initial certification, at each

recertification and at each interim certification, if applicable. In

addition, when new adult members join the household and when

members of the household become 18 years of age they must also

sign the relevant consent forms.

Persons who apply for or receive assistance under the following

progr

ams must sign the relevant consent forms:

Renta

l Assistance Program (RAP)

Rent Supplement

Section 8 Housing Assistance Payments Programs (administered by

the Office of Housing)

Section 202

Sections 202 and 811 PRAC

Section 202/162 PAC

Section 221(d)(3) Below Market Interest Rate

Section 236

HOPE 2 Home Ownership of Multifamily Units

information that you have provided which will affect the amount of rent you

pay. The information includes income and assets, such as salary, welfare

benefits, and interest earned on savings accounts. They also include certain

adjustments to your income, such as the allowances for dependents and for

households whose heads or spouses are elderly handicapped, or disabled;

and allowances for child care expenses, medical expenses, and handicap

assistance expenses.

riginal is retained on file at the project site

ref. Handbooks 4350.3 Rev-1, 4571.1, 4571.2 & 4571.3 form HUD-9887-A (02/2007)

and HOPE II Notice of Program Guidelines

Failure to Sign the Consent Form

Failure to sign any required consent form may result in the denial of

assistance or termination of assisted housing benefits. If an

applicant is denied assistance for this reason, the O/A must follow

the notification procedures in Handbook 4350.3 Rev. 1. If a tenant

is denied assistance for this reason, the O/A must follow the

procedures set out in the lease.

Conditions

No action can be taken to terminate, deny, suspend or reduce the

assistance your household receives based on information obtained

about you under this consent until the O/A has independently 1)

verified the information you have provided with respect to your

eligibility and level of benefits and 2) with respect to income

(including both earned and unearned income), the O/A has verified

whether you actually have (or had) access to such income for

your

own use, and verified the period or periods when, or with respect

to which

you actually received such income, wages, or benefits.

A photocopy of the signed consent may be used to request the

information authorized by your signature on the individual consent

forms. This would occur if the O/A does not have another

individual verification consent with an original signature and the

O/A is required to send out another request for verification (for

example, the third party fails to respond). If this happens, the O/A

may attach a photocopy of this consent to a photocopy of the

individual verification form that you sign. To avoid the use of

photocopies, the O/A and the individual may agree to sign more

than one consent for each type of verification that is needed.

The O/A shall inform you, or a third party which you designate,

of the findings made on the basis of information verified under this

consent and shall give you an opportunity to contest such findings

in accordance with Handbook 4350.3 Rev. 1.

The O/A must provide you with information obtained under this

consent in accordance with State privacy laws.

If a member of the household who is required to sign the consent

forms is unable to sign the required forms on time, due to extenuating circum-

Penalties for Misusing this Consent:

stances, the O/A may document the file as to the reason for the delay and

the specific plans

to obtain the proper signature as soon as possible.

Individual consents to the release of information expire 15 months

after they are signed. The O/A may use these individual consent

forms during the 120 days preceding the certification period. The

O/A may also use these forms during the certification period, but

only in cases where the O/A receives information indicating that

the information you have provided may be incorrect. Other uses are

prohibited.

The O/A may not make inquiries into information that is older than 12

months un

less he/she has received inconsistent information and has

reason to believe that the information that you have supplied is

incorrect. If this occurs, the O/A may obtain information within the last

5 years when you have received assistance.

I have read and understand this information on the purposes

and uses of

information that is verified and consent to the

release of information for these purposes and uses.

_______________________________________________________

Name of Applicant or Tenant (Print)

_______________________________________________________

Signature of Applicant or Tenant & Date

I have read and understand the purpose of this consent and its

uses and I understand that misuse of this consent can lead to

personal penalties to me.

_______________________________________________________

Name of Project Owner or his/her representative

_______________________________________________________

Title

_______________________________________________________

Signature & Date

cc:Applicant/Tenant

Owner file

HUD, the O/A, and any PHA (or any employee of HUD, the O/A, or the PHA) may be subject to penalties for unauthorized disclosures or improper

uses of information collected based on the consent form.

Use of the information collected based on the form HUD 9887-A is restricted to the purposes cited on the form HUD 9887-A. Any person who

knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or tenant may be subject to a

misdemeanor and fined not more than $5,000.

Any applicant or tenant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be

appropriate, against the officer or employee of HUD, the O/A or the PHA responsible for the unauthorized disclosure or improper use.

Original is retained on file at the project site ref. Handbooks 4350.3 Rev. 1, 4571.1, 4571.2 & 4571.3 form HUD-9887-A (02/2007)

and HOPE II Notice of Program Guidelines

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