Pbv Application Packet - Housing Authority Of Snohomish County Page 23
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38The Housing Authority of Snohomish County
th
12711 4
Ave. W, Everett, WA 98204
Phone:425-290-8499; Fax: 425-290-5618
AUTHORIZATION FOR RELEASE OF INFORMATION
TO THE HOUSING AUTHORITY OF SNOHOMISH COUNTY
I authorize the release of any information deemed pertinent by the Housing Authority of Snohomish
County for establishing eligibility or continued participation in any of the agency’s housing assistance
programs. I agree that photocopies of this authorization may be used for these purposes. Requested
information includes, but is not limited to any of the following:
1. Childcare and disability assistance expenses.
2. Medical expenses including, but not limited to, regular monthly payments for medical bills, hospital
services, health insurance premiums, co-pays, prescription costs, vision costs, dental treatment,
medical equipment, or any other medical expense allowed under IRS Publication 502.
3. Information from previous landlords, law enforcement agencies, criminal checks through ACRAnet,
courts, credit bureaus, schools, utilities, etc. for the purpose of screening prospective tenants.
4. Information regarding any minor or foster children.
5. Any information on past history required for any of the above.
All adult members in your household must print their name and provide their signature below.
Head of Household:
Print name
Signature
Date
Other Adult Member:
Print name
Signature
Date
Other Adult Member:
Print name
Signature
Date
Other Adult Member:
Print name
Signature
Date
This release is intended only for the use of the individual or entity to which it is addressed, and it may
contain information that is privileged and confidential. Any dissemination, distribution or copying of
this form is strictly prohibited by other parties.
Equal Housing Opportunity
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