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 6
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6stances, the O/A may document the file as to the reason for the delay and
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the specific plans to obtain the proper signature as soon as possible.
Failure to sign any required consent form may result in the denial of
Individual consents to the release of information expire 15 months
assistance or termination of assisted housing benefits. If an
after they are signed. The O/A may use these individual consent
applicant is denied assistance for this reason, the O/A must follow
forms during the 120 days preceding the certification period. The
the notification procedures in Handbook 4350.3 Rev. 1. If a tenant
O/A may also use these forms during the certification period, but
is denied assistance for this reason, the O/A must follow the
only in cases where the O/A receives information indicating that
procedures set out in the lease.
the information you have provided may be incorrect. Other uses are
prohibited.
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No action can be taken to terminate, deny, suspend or reduce the
The O/A may not make inquiries into information that is older than 12
assistance your household receives based on information obtained
months unless he/she has received inconsistent information and has
about you under this consent until the O/A has independently 1)
reason to believe that the information that you have supplied is
verified the information you have provided with respect to your
incorrect. If this occurs, the O/A may obtain information within the last
5 years when you have received assistance.
eligibility and level of benefits and 2) with respect to income
(including both earned and unearned income), the O/A has verified
whether you actually have (or had) access to such income for your
I have read and understand this information on the purposes
and uses of information that is verified and consent to the
own use, and verified the period or periods when, or with respect to which
release of information for these purposes and uses.
you actually received such income, wages, or benefits.
A photocopy of the signed consent may be used to request the
information authorized by your signature on the individual consent
_______________________________________________________
forms. This would occur if the O/A does not have another
individual verification consent with an original signature and the
Name of Applicant or Tenant (Print)
O/A is required to send out another request for verification (for
example, the third party fails to respond). If this happens, the O/A
may attach a photocopy of this consent to a photocopy of the
_______________________________________________________
individual verification form that you sign. To avoid the use of
Signature of Applicant or Tenant & Date
photocopies, the O/A and the individual may agree to sign more
than one consent for each type of verification that is needed.
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The O/A shall inform you, or a third party which you designate,
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of the findings made on the basis of information verified under this
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consent and shall give you an opportunity to contest such findings
)
in accordance with Handbook 4350.3 Rev. 1.
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
Name of Project Owner or his/her representative
The O/A must provide you with information obtained under this
consent in accordance with State privacy laws.
_______________________________________________________
Title
If a member of the household who is required to sign the consent
_______________________________________________________
forms is unable to sign the required forms on time, due to extenuating circum-
Signature & Date
cc:Applicant/Tenant
Owner file
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HUD, the O/A, and any PHA (or any employee of HUD, the O/A, or the PHA) 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 9887-A is restricted to the purposes cited on the form HUD 9887-A. Any person who
knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or tenant may be subject to a
misdemeanor and fined not more than $5,000.
Any applicant or tenant 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 O/A or the PHA responsible for the unauthorized disclosure or improper use.
Original is retained on file at the project site
ref. Handbooks 4350.3 Rev. 1, 4571.1, 4571.2 & 4571.3
form BC!DEFFGD0)(02/2007)
and HOPE II Notice of Program Guidelines
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