Pre-Application For Public Housing Page 4
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4MISSISSIPPI REGIONAL HOUSING AUTHORITY IV
P.O. BOX 1051
COLUMBUS, MS 39703-1051
PHONE (662) 327-4121 / FAX (662) 327-4344
HEARING AND SPEECH IMPAIRED (662) 327-8114
Authorization for Release of Information
CONSENT:
I authorize and direct any Federal, State, or local agencies, organization, business or individual to
release to the Mississippi Regional Housing Authority IV any information regarding my application for
participation, and\or to maintain my continued assistance under the Section 8 Rental Assistance, Low-
Income Public and Indian Housing, and/or other housing assistance programs. I understand and agree
that this authorization and the information obtained with its use will be given to and used by the
Mississippi Regional Housing Authority IV in administering and enforcing program rules and policies.
________________________
Date
INFORMATION COVERED
I understand that, depending on program policies and requirements, previous or current information
regarding me or my household may be needed. Verifications and inquiries that may be requested,
include, but are not limited to:
Identity and Martial Status
Employment, Income and Assets
Medical or Child Care Allowances
Credit Reports, Landlord References
Criminal Activity (which may include a NCIC
search and drug related activities)
GROUPS OR INDIVIDUALS THAT MAY BE ASKED
The groups or individuals that may be asked to release the above information (depending on program
requirements) include but are not limited to:
Previous Landlords (Including
Past and Present Employers
Other PHAs)
Department of Human Services
Courts and Post Offices
State Unemployment Agencies
Schools and Colleges
Social Security Administration
Law Enforcement Agencies
Support and Alimony Providers
Medical and Child Care Providers
Veterans Administrations
Retirement Systems
Banks and other Financial Institutions
Utility Companies
Credit Providers and Credit Bureaus
EIV (UIV) System
Pharmacies
CONDITIONS
I agree that a photocopy of this authorization may be used for the purposes stated above. The original of
this authorization is on file in the management office. I understand I have a right to review my file and
correct any information that I can document as incorrect.
________________________________
_________________ ___________________________
Name (Signature)
DOB
SS#
________________________________
_________________ ___________________________
Name (Signature)
DOB
SS#
________________________________
_________________ ___________________________
Name (Signature)
DOB
SS#
________________________________
_________________ ___________________________
Name (Signature)
DOB
SS#
rev11/14
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