0MB CONTROL NUMBER: 2501-0014
PHA requesting release of information; (Cross out space if none)
(Full address, name of contact person, and date)
Housing Authority of Covington 2300 Madison Ave.
Covington, KY 41014
IHA requesting release of information: (Cross out space if none)
(Full address, name of contact person, and date)
Authority: Section 904 of the Stewart B. McKinney Homeless Assistance Amendments Act of 1988, as amended by Section 903 of the Housing and Community Development Act of 1992 and Section 3003 of the Omnibus Budget Reconciliation Act of 1993. This law is found at 42 U.S .C. 3544.
This law requires that you sign a consent form authorizing: (1) HUD and the Housing Agency/Authority (HA) to request verification of salary and wages from current or previous employers; (2) HUD and the HA to request wage and unemployment compensation claim information from the state agency responsible for keeping that information; (3) HUD to request certain tax return information from the U.S. Social Security Administration and the
U.S . Internal Revenue Service. The law also requires independent verification of income information . Therefore, HUD or the HA may request information from financial institutions to verify your eligibility and level of benefits.
Purpose: In signing this consent form, you are authorizing HUD and the above-named HA to request income information from the sources listed on the form. HUD and the HA need this information to verify your household’s income, in order to ensure that you are eligible for assisted housing benefits and that these benefits are set at the correct level. HUD and the HA may participate in computer matching programs with these sources in order to verify your eligibility and level of benefits.
Uses of Information to be Obtained: HUD is required to protect the income information it obtains in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. HUD may disclose information (other than tax return information) for certain routine uses, such as to other government agencies for law enforcement purposes, to Federal agencies for employment suitability purposes and to HAs for the purpose of determining housing assistance. The HA is also required to protect the income information it obtains in accordance with any applicable State privacy law. HUD and HA employees may be subject to penalties for unauthorized disclosures or improper uses of the income information that is obtained based on the consent form. Private owners may not request or receive information authorized by this form.
Who Must Sign the Consent Form: Each member of your household who is 18 years of age or older must sign the consent form. Additional signatures must be obtained from new adult members joining the household or whenever members of the household become 18 years of age.
Persons who apply for or receive assistance under the following programs are required to sign this consent form:
Failure to Sign Consent Form: Your failure to sign the consent form may result in the denial of eligibility or termination of assisted housing benefits, or both. Denial of eligibility or termination of benefits is subject to the HA ‘s grievance procedures and Section 8 informal hearing procedures.
Sources of Information To Be Obtained
State Wage Information Collection Agencies. (This consent is limited to wages and unemployment compensation I have received during period(s) within the last 5 years when I have received assisted housing benefits.)
U.S. Social Security Administration (HUD only) (This consent is limited to the wage and self employment information and payments of retirement income as referenced at Section 6103(1)(7)(A) of the Internal Revenue Code.)
U.S. Internal Revenue Service (HUD only) (This consent is limited to unearned income [i.e., interest and dividends].)
Information may also be obtained directly from: (a) current and former employers concerning salary and wages and (b) financial institutions concerning unearned income (i.e., interest and dividends) . I understand that income information obtained from these sources will be used to verify information that I provide in determining eligibility for assisted housing programs and the level of benefits. Therefore, this consent form only authorizes release directly from employers and financial institutions of information regarding any period(s) within the last 5 years when I have received assisted housing benefits.
Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair Housing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S .C. 3543) requires applicants and participants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoring HUD-assisted housing programs, to protect the Government’s financial interest, and to verify the accuracy of the information you provide. This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatory investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. 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, against the officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use.
Income Based Rent:
Income based rent method is calculated through your annual income. The total tenant payment (tenant rent) is equal to the highest of:
To determine annual income, the Housing Authority of Covington adds the income of all adult family members; once this is determined the authority subtracts all allowable deductions (allowances) to determine the tenant rent.
Flat rent is a set amount of rent for the bedroom size of the apartment based on market rent in the public sector. The Housing Authority of Covington expects to review the amount of the flat rent on a yearly basis. A 30 day notice of a rent increase will be issued. Deductions are not applicable with this option. This option can only be changed once a year at your annual re-examination.
I have read the Notice of Reinstatement of the Community Service requirement and certify that:
Please indicate below with your initials which exemption applies to your situation:
If you or anyone in your family is a person with disabilities, and you require a specific accommodation in order to fully utilize our programs and services, please contact the housing authority.
Maximum number of entries reached.
List all persons’ age 18 or older who will be living in the home (and head/spouse/co-head regardless of age), beginning with the head of household. Each box must be completed for each member. No one except those listed on this form may live in the unit.
List all children who will be living in the home, oldest to youngest.
These questions apply to you and all of the members of your household.
(Income includes money or contributions from any and all sources paid to or on behalf of a family member.)
(An asset is something of value that can be converted to cash)
WARNING: TITLE 18, SECTION 1001 OF THE UNITED STATES CODE STATES THAT A PERSON Is GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT
STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AND SHALL BE FINED NOT MORE THAN $10,000 OR IMPRISONED FOR NOT MORE THAN FIVE YEARS OR BOTH.
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