Form Hud-9886 - Authorization For The Release Of Information / Privacy Act Notice - U.s. Department Of Housing And Urban Development
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2Authorization for the Release of Information/
U.S. Department of Housing
and Urban Development
Privacy Act Notice
Office of Public and Indian Housing
to the U.S. Department of Housing and Urban Development (HUD)
OMB CONTROL NUMBER: 2501-0014
and the Housing Agency/Authority (HA)
exp. 1/31/2014
PHA requesting release of information; (Cross out space if none)
IHA requesting release of information: (Cross out space if none)
(Full address, name of contact person, and date)
(Full address, name of contact person, and date)
Authority: Section 904 of the Stewart B. McKinney Homeless
Persons who apply for or receive assistance under the following
Assistance Amendments Act of 1988, as amended by Section 903
programs are required to sign this consent form:
of the Housing and Community Development Act of 1992 and
PHA-owned rental public housing
Section 3003 of the Omnibus Budget Reconciliation Act of 1993.
Turnkey III Homeownership Opportunities
This law is found at 42 U.S.C. 3544.
Mutual Help Homeownership Opportunity
This law requires that you sign a consent form authorizing: (1)
Section 23 and 19(c) leased housing
HUD and the Housing Agency/Authority (HA) to request verifi-
cation of salary and wages from current or previous employers; (2)
Section 23 Housing Assistance Payments
HUD and the HA to request wage and unemployment compensa-
HA-owned rental Indian housing
tion claim information from the state agency responsible for
Section 8 Rental Certificate
keeping that information; (3) HUD to request certain tax return
Section 8 Rental Voucher
information from the U.S. Social Security Administration and the
U.S. Internal Revenue Service. The law also requires independent
Section 8 Moderate Rehabilitation
verification of income information. Therefore, HUD or the HA
Failure to Sign Consent Form: Your failure to sign the consent
may request information from financial institutions to verify your
form may result in the denial of eligibility or termination of
eligibility and level of benefits.
assisted housing benefits, or both. Denial of eligibility or termi-
Purpose: In signing this consent form, you are authorizing HUD
nation of benefits is subject to the HA’s grievance procedures and
and the above-named HA to request income information from the
Section 8 informal hearing procedures.
sources listed on the form. HUD and the HA need this information
Sources of Information To Be Obtained
to verify your household’s income, in order to ensure that you are
State Wage Information Collection Agencies. (This consent is
eligible for assisted housing benefits and that these benefits are set
limited to wages and unemployment compensation I have re-
at the correct level. HUD and the HA may participate in computer
ceived during period(s) within the last 5 years when I have
matching programs with these sources in order to verify your
received assisted housing benefits.)
eligibility and level of benefits.
U.S. Social Security Administration (HUD only) (This consent is
Uses of Information to be Obtained: HUD is required to protect
limited to the wage and self employment information and pay-
the income information it obtains in accordance with the Privacy
ments of retirement income as referenced at Section 6103(l)(7)(A)
Act of 1974, 5 U.S.C. 552a. HUD may disclose information
of the Internal Revenue Code.)
(other than tax return information) for certain routine uses, such as
to other government agencies for law enforcement purposes, to
U.S. Internal Revenue Service (HUD only) (This consent is
Federal agencies for employment suitability purposes and to HAs
limited to unearned income [i.e., interest and dividends].)
for the purpose of determining housing assistance. The HA is also
Information may also be obtained directly from: (a) current and
required to protect the income information it obtains in accordance
former employers concerning salary and wages and (b) financial
with any applicable State privacy law. HUD and HA employees
institutions concerning unearned income (i.e., interest and divi-
may be subject to penalties for unauthorized disclosures or im-
dends). I understand that income information obtained from these
proper uses of the income information that is obtained based on the
sources will be used to verify information that I provide in
consent form. Private owners may not request or receive
determining eligibility for assisted housing programs and the level
information authorized by this form.
of benefits. Therefore, this consent form only authorizes release
Who Must Sign the Consent Form: Each member of your
directly from employers and financial institutions of information
household who is 18 years of age or older must sign the consent
regarding any period(s) within the last 5 years when I have
form. Additional signatures must be obtained from new adult
received assisted housing benefits.
members joining the household or whenever members of the
household become 18 years of age.
form HUD-9886 (7/94)
ref. Handbooks 7420.7, 7420.8, & 7465.1
Original is retained by the requesting organization.
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