Authorization for Release of Information

(To be completed by all household members over the age of 18 years)

Name: _________________________________________________

Address: _______________________________________________________________________________

I, the above named individual, have authorized the Attleboro Housing Authority to verify the accuracy of the information, which I have provided to the Housing Authority, from the following sources:

Criminal Offenders Records Information Employer / D.E.T.

Welfare Social Security

Credit Report Physician

Other: Internal Revenue Service; Department of Revenue

I hereby give you my permission to release this information to the Attleboro Housing Authority subject to the condition that it be kept confidential. I would appreciate your prompt attention in supplying the information requested on the attached page to the Attleboro Housing Authority within five (5) days of receipt of this request.

I understand that a photocopy of this Authorization is as valid as the original.

Thank you for your assistance and cooperation in this matter.

_______________________________________________ ________________________

Signature Date

Fair Information Practices Act – Statement of Rights

The Attleboro Housing Authority collects information about applicants and tenants for its housing programs as required by law in order to determine eligibility, amount of rent and correct apartment size. The information collected is used to manage the housing programs, to protect the public’s financial interest and to verify the accuracy of information submitted. When permitted by law, it may be released to government agencies, other housing authorities and to civil or criminal investigators and prosecutors. Otherwise, the information will be kept confidential and only used by Housing Authority staff in the course of their duties.

The Fair Information Practices Act established requirements governing housing authorities’ use and disclosure of the information it collects. Applicants and tenants may give or withhold their permission when requested by the Housing Authority to provide information; however, failure to permit the Housing Authority to obtain the required information may result in delay, ineligibility for programs or termination of tenancy or housing subsidy. The provision of false or incomplete information is a criminal offense punishable by fines and/or imprisonment. As an applicant or tenant, you have the following rights in regard to the information collected about you. No information may be used for any purpose other than those described above without your consent.

1. No information may be disclosed to any person other than those described above without your consent. If we receive legal order to release the information, we will notify you.

2. You or your authorized representative has a right to inspect and copy any information. However, the Housing Authority reserves the right for a 24-hour notice in such cases in order to have someone available to assist you.

3. You may ask questions and receive answers from the Housing Authority about how we collect and use information.

4. You may object to the collection, maintenance, dissemination, use, accuracy, completeness or type of information we hold about you. If you object, we will investigate your objection and will either correct the problem or make your objection part of your file. If you are dissatisfied, you may appeal to The Department of Housing and Community Development.

I have read and understand this Fair Information Practices Statement of Rights.

_______________________________________________ ________________________

Signature Date