Form Hud-9886 - Authorization For The Release Of Information / Privacy Act Notice - U.s. Department Of Housing And Urban Development Page 2

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Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form for

the purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs that

receive income information under this consent form cannot use it to deny, reduce or terminate assistance without first

independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In

addition, I must be given an opportunity to contest those determinations.

This consent form expires 15 months after signed.

Signatures:

_____________________________________________

______________

Head of Household

Date

___________________________________________

__________________________________________________

________________

Social Security Number (if any) of Head of Household

Other Family Member over age 18

Date

__________________________________________________

_______________

__________________________________________________

________________

Spouse

Date

Other Family Member over age 18

Date

__________________________________________________

_______________

__________________________________________________

________________

Other Family Member over age 18

Date

Other Family Member over age 18

Date

__________________________________________________

_______________

__________________________________________________

________________

Other Family Member over age 18

Date

Other Family Member over age 18

Date

Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information

by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair

Housing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and

participants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and

other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family

will pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoring

HUD-assisted housing programs, to protect the Government’s financial interest, and to verify the accuracy of the information you provide.

This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatory

investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted

or required by law. Penalty: You must provide all of the information requested by the HA, including all Social Security Numbers you,

and all other household members age six years and older, have and use. Giving the Social Security Numbers of all household members

six years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provide

any of the requested information may result in a delay or rejection of your eligibility approval.

Penalties for Misusing this Consent:

HUD, the HA and any owner (or any employee of HUD, the HA 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 the form HUD 9886 is restricted to the purposes cited on the form HUD 9886. Any person who knowingly or willfully

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, the HA or the owner responsible for the unauthorized disclosure or improper use.

ref. Handbooks 7420.7, 7420.8, & 7465.1

form HUD-9886 (7/94)

Original is retained by the requesting organization.