Form Hud-9887 And 9887-A - Document Pachagefor Applicant'S/tenant'S Concent To The Release Of Information - U.s. Department Of Housing And Urban Development Page 3

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CAIA)!&1+/(%&'()".)B"$53'-)

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+'>)C/J+')!&L&2"1%&'()

Office of Housing

to the U.S. Department of Housing and Urban Development (HUD) and to

Federal Housing Commissioner

an Owner and Management Agent (O/A), and to a Public Housing

Agency (PHA)

O/A

requesting

release

HUD Office requesting release of information

PHA requesting release of information (Owner should

provide the full name and address of the PHA and the title of

(Owner should provide the full address of the

information (Owner should provide the full

name and address of the Owner.):

the director or administrator. If there is no PHA Owner or

HUD Field Office, Attention: Director, Multifamily

PHA contract administrator for this project, mark an X

Division.):

through this entire box.):

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0$(9"/3(K: Section 217 of the Consolidated Appropriations Act of 2004

information it obtains in accordance with any applicable State privacy law.

(Pub L. 108-199). This law is found at 42 U.S.C.653(J). This law authorizes

After receiving the information covered by this notice of consent, HUD, the

HHS to disclose to the Department of Housing and Urban Development

O/A, and the PHA may inform you that your eligibility for, or level of, assistance

(HUD) information in the NDNH portion of the “Location and Collection

is uncertain and needs to be verified and nothing else.

System of Records” for the purposes of verifying employment and income of

HUD, O/A, and PHA employees may be subject to penalties for unauthorized

individuals participating in specified programs and, after removal of personal

disclosures or improper uses of the income information that is obtained based

identifiers, to conduct analyses of the employment and income reporting of

on the consent form. )

these individuals. Information may be disclosed by the Secretary of HUD to a

private owner, a management agent, and a contract administrator in the

[9")T$5()I3-')(9&)8"'5&'()H"/%? Each member of your household who is

administration of rental housing assistance.

at least 18 years of age and each family head, spouse or co-head, regardless of

Section 904 of the Stewart B. McKinney Homeless Assistance Amendments

age, must sign the consent form at the initial certification and at each

Act of 1988, as amended by section 903 of the Housing and Community

recertification. Additional signatures must be obtained from new adult

Development Act of 1992 and section 3003 of the Omnibus Budget

members when they join the household or when members of the household

Reconciliation Act of 1993. This law is found at 42 U.S.C. 3544.This law

become 18 years of age.

requires you to sign a consent form authorizing: (1) HUD and the PHA to

Persons who apply for or receive assistance under the following programs are

request wage and unemployment compensation claim information from the

required to sign this consent form:

state agency responsible for keeping that information; and (2) HUD, O/A, and

the PHA responsible for determining eligibility to verity salary and wage

Rental Assistance Program (RAP)

information pertinent to the applicant’s or participant’s eligibility or level of

benefits; (3) HUD to request certain tax return information from the U.S.

Rent Supplement

Social Security Administration (SSA) and the U.S. Internal Revenue Service (IRS).

Section 8 Housing Assistance Payments Programs (administered by the

*$/1"5&? In signing this consent form, you are authorizing HUD, the above-

Office of Housing)

named O/A, and the PHA to request income information from the government

Section 202; Sections 202 and 811 PRAC; Section 202/162 PAC Section

agencies listed on the form. HUD, the O/A, and the PHA need this

information to verify your household’s income to ensure that you are eligible

221(d)(3) Below Market Interest Rate

for assisted housing benefits and that these benefits are set at the correct

level. HUD, the O/A, and the PHA may participate in computer matching

Section 236

programs with these sources to verify your eligibility and level of benefits.

HOPE 2 Homeownership of Multifamily Units

This form also authorizes HUD, the O/A, and the PHA to seek wage, new hire

(W-4), and unemployment claim information from current or former employers

H+32$/&) (")I3-' )8"' 5&'()H "/%?) Your failure to sign the consent form may

to verify information obtained through computer matching.

result in the denial of assistance or termination of assisted housing benefits. If

an applicant is denied assistance for this reason, the owner must follow the

)C5&5) ".)<' ."/%+(3"')(" )J& );J (+3'&>?) HUD is required to protect the income

notification procedures in Handbook 4350.3 Rev. 1. If a tenant is denied

information it obtains in accordance with the Privacy Act of 1974,

assistance for this reason, the owner or managing agent must follow the

5 U.S.C. 552a. The O/A and the PHA is also required to protect the income

procedures set out in the lease.

________________________________________________________________________________________________________________________________

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Signatures:

Additional Signatures, if needed:

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Head of Household

Date