AUTHORIZATION FOR RELEASE OF INFORMATION CONSENT I authorize and direct any Federal, State or local agency organization, business, or individuals to r
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9 AUTHORIZATION FOR RELEASE OF INFORMATION CONSENT I authorize and direct any Federal, State or local agency organization, business, or individuals to release to Scott County Community Development Agency any information or materials needed to complete and verify my application for participation, and/or to maintain my continued assistance under the Housing Choice Voucher, Public Housing, Rural Development, Workforce Housing and/or any other housing programs administered by the CDA. I understand and agree that this authorization or the information obtained with its use may be given to and used by the Department of Housing and Urban Development (HUD), Rural Development or Minnesota Housing Finance Agency in administering and enforcing program rules and policies. INFORMATION COVERED I understand that, depending on program policies and requirements, previous or current information regarding me or my household may be needed. Verifications and inquiries that may be requested include but are not limited to: Identity and Marital Status Employment, Income and Assets Residences and Rental Activity Medical or Child Care Allowance Credit and Criminal Activity I understand that this authorization will be used to obtain information about me that is pertinent to my eligibility for and continued participation in a housing assistance program. GROUPS OR INDIVIDUALS THAT MAY BE ASKED The groups or individuals that may be asked to release the above information (depending on program requirements) include but are not limited to: Previous landlords (including Public Housing Agencies) Past and Present Employers Veterans Administration Banks and other Financial Institutions Courts and Post Offices Welfare Agencies Credit providers and Credit Bureaus Law Enforcement Agencies Retirement Systems State Unemployment Agencies Social Security Administration Utility Companies Support and Alimony Providers Medical and Child Care Providers Schools and Colleges COMPUTER MATCHING NOTICE AND CONSENT I understand and agree that HUD or the Public Housing Authority may conduct computer matching programs to verify the information supplied for my application or recertification. If a computer match is done, I understand that I have a right to notification of any adverse information found and a chance to disprove that information. HUD, Rural Development or Scott County CDA may in the course of its duties exchange such automated information with other Federal, State, or local agencies, including but not limited to: State Employment Security Agencies; Department of Defense; Office of Personnel Management; the U.S. Postal Service; the Social Security Agency; and State welfare and food stamp agencies. AUTHORIZATION FOR FRAUD INVESTIGATIONS AND AUDITS I understand and agree that third parties may share information about me with the Scott County CDA for fraud investigations and for conducting Federal or State audits. In addition, I understand and agree that Scott County CDA may share information about me with other government entities to the extent permitted by law or to investigate allegations of fraud by these entities. CONDITIONS I agree that a photocopy of this authorization may be used for the purposes stated above. This authorization will stay in effect for one year and one month from the date signed. Head of Household SIGNATURE PRINT NAME DATE Spouse Adult Member Adult Member Adult Member
10 YOUR PRIVACY RIGHTS This sheet tells you about your rights under the Minnesota Data Practices Act. This Act protects your privacy, but also lets us give information about you to others if a law requires it and we tell you before we do it. This sheet tells why and when we will ask for and give information about you. It applies to all future contacts you have with this agency. Those contacts may be in person, by mail, or on the telephone. WHY DO WE ASK YOU FOR INFORMATION? We may ask you for information so we can: Tell you from other persons by the same or similar name. Decide if you can get money or services from us and what or how much you can get. Collect money from the state or federal government for help we give to you. Make reports, do research, audit and evaluate our programs. Investigate reports of people who may lie about the help they need. DO YOU HAVE TO ANSWER THE QUESTIONS WE ASK? Generally, the law does not say you have to give us this information. Federal laws require that you give us your Social Security number and the Social Security number of all members of your household age six or older if you want housing assistance. WHAT WILL HAPPEN IF YOU DO NOT ANSWER THE QUESTIONS WE ASK? We need information about you to tell if you can get help from this agency. Without some information, we may not be able to help you. It may be that we can help you but the help may be late or not enough. Giving us wrong information on purpose may result in investigating and charging you with fraud. WHO MAY WE SHARE THE INFORMATION ABOUT YOU WITH? We may give information about you to the following agencies. This does not mean we always share information about you with these people, but there is a law that says we may share with these people sometimes. U.S. Department of Housing and Urban Development U.S. Department of Health and Human Services Credit bureaus County attorney, attorney general, or other law enforcement officials Minnesota Department of Human Services State and federal auditors Other housing authorities YOU HAVE THE RIGHT TO COPIES OF INFORMATION WE HAVE ABOUT YOU You may ask if we have any information about you. If we have information about you, you may ask for copies. You may have to pay for the copies. You may give other people permission to see and have copies of private data about you. If the information is unclear, you may ask to have it explained to you. WHAT YOU CAN DO IF YOU THINK INFORMATION ABOUT YOU IS NOT ACCURATE OR COMPLETE Your objection must be in writing and be sent to the head of this agency. You must tell us why the information is not accurate or complete. You may send your own explanation of the facts with which you do not agree. For more information on how to do this, ask your agency representative. WHAT PRIVACY RIGHTS DO CHILDREN HAVE? If you are under 18, your parents may see data about you and authorize others to see this data, unless you have asked that this information not be shared with your parents. You must make this request in writing and say what data you want withheld and why. If this agency agrees with you that not sharing the data would be in your best interest, we will not share the data with your parents. If we don t agree with you, the data may be shared with your parents if they ask for it. IF YOU HAVE QUESTIONS ABOUT THE INFORMATION ON THIS FORM, ASK YOUR AGENCY REPRESENTATIVE. Client Signature Date
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