Supplement To Application For Federally Assisted Housing Template Page 4
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10BHA Use Only
AUTHORIZATION FOR RELEASE OF INFORMATION
I authorize and direct any federal, state, or local agency, organization, business, or individual to
release to the Housing Authority of the City of Bloomington any information or materials needed
to complete and verify my application for housing assistance and/or to maintain my continued
occupancy of housing furnished by or through the Housing Authority. I understand and agree that
this authorization or the information obtained with its use may be given to and used by the
Housing Authority in administering and enforcing program rules and policies.
I understand that, depending on program policies and requirements, previous or current
information regarding me or my household may be requested, this includes but is not limited
to:
Identity and Marital Status
Residences and Rental Activity
Income
Medical Allowances
Child Care Allowances
Credit and Criminal Activity
I understand that this authorization cannot be used to obtain any information about me that is not
pertinent to my eligibility and continued participation in a housing assistance program.
The groups or individuals that may be asked to release the above information (depending on
program requirements) include but are not limited to:
Previous Landords
Veterans Administration
Social Security Administration
Retirement/Pension
FSSA
Utility Companies
Public Housing Agencies
Schools and Colleges
Work One
Law Enforcement Agencies
Credit Bureaus and Providers
Employers
Support and Alimony Providers
Financial Institutions (Banks)
Medical Providers
Child Care Providers
Courts
I understand and agree that the Housing Authority may conduct computer matching programs to
verify the information supplied for my application or recertification. If a computer match is done,
I understand that I have a right to exchange such automated information with other federal, state,
or local agencies, including but not limited to State Employment Security agencies; Department
of Defense; Office of Personnel Management; U. S. Postal Service; Social Security Agency and
State Welfare and food stamp agencies.
I agree that a photocopy of this authorization may be used for the purposes listed above. This
authorization will stay in effect for as long as I remain an applicant/participant/resident in any
housing program administered by the Housing Authority.
I understand refusal to sign this or any required consent form may result in the denial of
assistance or the termination of assisted housing benefits.
DATE
SIGNATURE
PRINT NAME
Head of Household
Adult Member
Adult Member
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