Nt1330 Unit 2 Assignment

Authorization for the Release of Information/
Privacy Act Notice

to the U.S. Department of Housing and Urban Development (HUD) and the Housing Agency/Authority (HA)

U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
OMB CONTROL NUMBER: 2501-0014 exp. 1/31/2014

PHA requesting release of information; (Cross out space if none)
(Full address, name of contact person, and date)

IHA requesting release of information: (Cross out space if none)
(Full address, name of contact person, and date)

Cumberland County Housing Authority
114 N. Hanover St.
Carlisle, PA 17013

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Authority: Section 904 of the Stewart B. McKinney Homeless
Assistance Amendments Act of
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,