Fillable Voucher Extension Request Form (Page 4 of 4) in pdf

AUTHORIZATION FOR RELEASE OF INFORMATION

Other Public Housing Agencies

Welfare Agencies

AUTHORITY:

Section 904 of the Stewart B. McKinney

Past and Present Employers

Medical Providers

Homeless Assistance Amendment Act of 1988, as amended by

Retirement Systems

Banks

Section 903 of the Housing and Community Development Act

Unemployment Agencies

Schools/Colleges

of 1992 and Section 3003 of the Omnibus Budget

Courts and Post Offices

Credit Unions

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

Veteran’s Administration

Utility Companies

3544. HUD is required to protect the income information it

Child Care Providers

Credit Providers

obtains in accordance with the Privacy Act of 1974, 5 U.S.C.

Support and Alimony Providers

Credit Bureaus

552a.

Social Security Administration

Local, State & Federal Law Enforcement Agencies

CONSENT:

I authorize and direct any Federal, State, or local

agency, organization, business, or individual to release to the

COMPUTER MATCHING NOTICE AND CONSENT:

Housing Authority of Maricopa County (HAMC), any

information or materials needed to complete and verify my

I understand and agree that HUD or the HAMC may conduct

application for participation, and/or maintain my continued

computer-matching programs to verify the information supplied

assistance under the Section 8 Housing Assistance Programs.

for my application and/or recertification. If a computer match is

I understand and agree that this Authorization or the

done, I understand that I have a right to notification of any

information obtained with its use may be given to and used by

adverse information found and a chance to disprove incorrect

information. HUD or the HAMC may in the course of it’s duties

the Department of Housing and Urban Development (HUD) in

administering and enforcing Program rules and policies.

exchange such automated information with other Federal,

State, or local agencies, including but not limited to State

INFORMATION COVERED

: I understand that, depending

Employment Security Agencies; Department of Defense; Office

on Program policies and requirements, previous or current

of Personnel Management; the U.S. Postal Service; the Social

information regarding my household or me may be needed.

Security Agency; and State Welfare and food stamp agencies.

Verifications and inquiries that may be requested include but

CONDITIONS: I agree that a photocopy of this Authorization

are not limited to:

may be used for the purposes stated above. The original of

Identity and Marital Status

Assets

this Authorization is on file with the HAMC and will stay in

Employment Income

Medical Allowances

effect for one year and one month from the date signed. I

Residences and Rental Activity

Criminal Activity

understand I have a right to review my file and correct any

Child Care Allowances

Credit Activity

information that I can prove is incorrect.

I understand that his Authorization cannot be used to obtain

PRIVACY ACT NOTICE: The following laws authorize

any information about me that is not pertinent to my eligibility

the collection of this information by HUD or the HAMC:

for, and continued participation in, a housing assistance

the U.S. Housing Act of 1937 (42 U.S.C., 1437 et seq.),

program.

Title VI of the Civil Rights Acts of 1964, and Title VIII of

the Civil Rights Act of

1968.

The Housing and

GROUPS OR INDIVIDUALS THAT MAY BE ASKED:

Community Development Act of 1987 (42 U.S.C. 3543)

requires applicants and residents to submit the Social

The groups or individuals that may be asked to release the

Security numbers of all household members at least six

above information (depending on Program requirements)

include, but are not limited to:

(6) years old.

HEAD OF HOUSEHOLD

SPOUSE OR 2

ADULT

PRINT NAME:

SIGNATURE:

DATE SIGNED:

OTHER ADULT (3

ADULT)

OTHER ADULT (4

ADULT)

PRINT NAME:

SIGNATURE:

DATE SIGNED:

Ave. Peoria, AZ 85345  p 602.744.4500  f 602.744.4545  TDD 602.744.4540

8910 N. 78

Voucher Extension Request Form Page 4

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