Pbv Application Packet - Housing Authority Of Snohomish County (Page 34 of 38) in pdf

OMB No. 2577-0266

Expires 08/31/2016

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, a PHA may terminate your current rental assistance and deny your future request for HUD rental assistance,

subject to PHA policy.

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, subject to 24 CFR Part 16.

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?

If you disagree with the reported information, you should contact in writing the PHA who has reported this information

about you. 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. HUD's record retention policies at 24 CFR Part 908

and 24 CFR Part 982 provide that the PHA may destroy your records three years from the date your participation in the

program ends. To ensure the availability of your records, disputes of the original debt or termination information must be

made within three years from the end of participation date; otherwise the debt and termination information will be

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:

Housing Authority of Snohomish County

12625 4th Avenue West, Suite 200

Signature

Date

Everett, WA 98204

Printed Name

08/2013

Form HUD-52675

Pbv Application Packet - Housing Authority Of Snohomish County Page 34

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