Eiv Applicant Notice Of Potential Rental History Conflict Form - Screening Page 2
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2PENALTIES FOR MISUSING THIS CONSENT: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for
knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or
any employee of HUD or the owner) 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 this verification form is restricted to the purposes cited above. Any
person who knowingly or willingly requests, obtains, or discloses any information under false pretenses concerning an applicant or
participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant 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 or the
owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are
contained in the Social Security Act at 42 USC 208 a(6)(7) and (8). Violations of these provisions are cited as violations of 42 USC 408 a (6)
(7) and (8).
Interstate Realty Management Company does not discriminate on the basis of disability status in the admission
or access to, or treatment or employment in, its federally assisted programs and activities.
Sandy Cipollone
Section 504 Coordinator
Interstate Realty Management Company
3 East Stow Road
Marlton, NJ 08053
Phone (856) 596-0500 Fax (856) 596-6093 TDD 711
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IR-953 - EIV Applicant Notice of Potential
Page
Created 3/2015
Rental History Conflict – Screening
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