Get At Home Program Forms

HOME Program Eligibility Release Form Organization requesting release of information PJ name address telephone and date Purpose Your signature on this HOME Program each member of your household who is 18 years of age or older authorizes the above-named organization to obtain information from a third party relative to your eligibility and continued participation in the Information Covered Inquiries may be made about items initialed by applicant/tenant. Other list Dependent Deduction Full-Time Student Handicap/Disabled Family Member Minor Children Authorization I authorize the above-named HOME Participating Jurisdiction and HUD to obtain information about me and my household that is pertinent to eligibility for participation in the I acknowledge that 1 A photocopy of this form is as valid as the original. Instructions Each adult member of the household must sign a HOME Program Eligibility Release For prior to the receipt of benefit and on an annual basis to establish continued eligibility. Verification Required Initials Income all sources Assets all sources Child Care Expense Handicap Assistance Expense if applicable HOME Homebuyer Program HOME Rental Rehabilitation Program HOME Homeowner Rehabilitation Program Medical Expense if applicable Privacy Act Notice Statement The Department of Housing and Urban Development HUD is requiring the collection of the information derived from this form to determine an applicant s eligibility in a HOME Program and the amount of assistance necessary using HOME funds. This information will be used to establish level of benefit on the HOME Program to protect the Government s financial interest and to verify the accuracy of the information furnished* It may be released to appropriate Federal State and local agencies when relevant to civil criminal or regulatory investigators and to prosecutors. Failure to provide any information may result in a delay or rejection of your eligibility approval* The Department is authorized to ask for this information by the National Affordable Housing Act of 1990. Additional signatures must be obtained from new adult members whenever they join the household or whenever members of the household become 18 years of age. 2 I have the right to review the file and the information received using this form with a person of my choosing to accompany me. this file and to request correction of information I believe inaccurate. 4 All adult household members will sign this form and cooperate with the owner in this process. NOTE THIS GENERAL CONSENT MAY NOT BE USED TO REQUEST A COPY OF A TAX RETURN* IF A COPY OF A TAX RETURN IS NEEDED IRS FORM 4506 REQUEST FOR COPY OF TAX FORM MUST BE PREPARED AND SIGNED SEPARATELY. Head of Household Signature Printed Name and Date Other Adult Member of the Household Signature Printed Name and Date X. Verification Required Initials Income all sources Assets all sources Child Care Expense Handicap Assistance Expense if applicable HOME Homebuyer Program HOME Rental Rehabilitation Program HOME Homeowner Rehabilitation Program Medical Expense if applicable Privacy Act Notice Statement The Department of Housing and Urban Development HUD is requiring the collection of the information derived from this form to determine an applicant s eligibility in a HOME Program and the amount of assistance necessary using HOME funds. This information will be used to establish level of benefit on the HOME Program to protect the Government s financial interest and to verify the accuracy of the information furnished* It may be released to appropriate Federal State and local agencies when relevant to civil criminal or regulatory investigators and to prosecutors.