Supplement To Application For Federally Assisted Housing Template Page 8
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10OMB No. 2577-0266
Expires 04/30/2013
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Who will have access to the information collected?
This information will be available to HUD employees, PHA employees, and contractors of HUD and PHAs.
How will this information be used?
PHAs will have access to this information during the time of application for rental assistance and reexamination of
family income and composition for existing participants. PHAs will be able to access this information to determine a
family’s suitability for initial or continued rental assistance, and avoid providing limited Federal housing assistance to
families who have previously been unable to comply with HUD program requirements. If the reported information is
accurate, your current rental assistance may be terminated and your future request for HUD rental assistance may be
denied for a period of up to ten years from the date you moved out of an assisted unit or were terminated from a HUD
rental assistance program.
How long is the debt owed and termination information maintained in EIV?
Debt owed and termination information will be maintained in EIV for a period of up to ten (10) years from the end of
participation date.
What are my rights?
In accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to its
implementation of the Federal Privacy Act of 1974 (24 CFR Part 16), you have the following rights:
1. To have access to your records maintained by HUD.
2. To have an administrative review of HUD’s initial denial of your request to have access to your records maintained
by HUD.
3. To have incorrect information in your record corrected upon written request.
4. To file an appeal request of an initial adverse determination on correction or amendment of record request within
30 calendar days after the issuance of the written denial.
5. To have your record disclosed to a third party upon receipt of your written and signed request.
What do I do if I dispute the debt or termination information reported about me?
You should contact the PHA, who has reported this information about you, in writing, if you disagree with the reported
information. The PHA’s name, address, and telephone numbers are listed on the Debts Owed and Termination Report.
You have a right to request and obtain a copy of this report from the PHA. Inform the PHA why you dispute the
information and provide any documentation that supports your dispute. Disputes must be made within three years
from the end of participation date. Otherwise the debt and termination information is presumed correct. Only the
PHA who reported the adverse information about you can delete or correct your record.
Your filing of bankruptcy will not result in the removal of debt owed or termination information from HUD’s EIV system.
However, if you have included this debt in your bankruptcy filing and/or this debt has been discharged by the
bankruptcy court, your record will be updated to include the bankruptcy indicator, when you provide the PHA with
documentation of your bankruptcy status.
The PHA will notify you in writing of its action regarding your dispute within 30 days of receiving your written dispute.
If the PHA determines that the disputed information is incorrect, the PHA will update or delete the record. If the PHA
determines that the disputed information is correct, the PHA will provide an explanation as to why the information is
correct.
This Notice was provided by the below-listed PHA:
I hereby acknowledge that the PHA provided me with the
Debts Owed to PHAs & Termination Notice:
Bloomington Housing Authority
1007 N Summitt Street
Bloomington, IN 47404
Signature
Date
Printed Name
April 26, 2010
Form HUD-52675
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