1999-08-23 Regular Meeting - Laserfiche WebLink

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HOME Program Eliaibilitv Release Form e SOUTHEAST TEXAS HOUSING FINANCE CORPORATION 12621 . Feathenlcod, Ste 280 Houston, Texas 77034 281-484-4663 DATE: Purpose: Your signature on this HOME Program Eligibility Release Form, and the signatures of 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: HOME Homebuyer Assistance Program Privacy Act Notices 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 benefits on the HOME Program: to protect the Govemmenrs financial interest; and to verify the accuracy of the information furnished. It may be released to appropriate Federal, State, and local agencies when relevant, . tf) civil, criminal, or regulatory investigators, and to prosecutors. Failure to provide any information may result in a delay or rejection of you erlQibility approval. The Department is authorized to ask for this information by the National Affordable Housing Act of 1990. Instructions: Each adult member of the household must sign a HOME Program Eligibility Release Form prior to the receipt of benefit and on an annual basis to establish continued eligibility. Additional signatures must be obtained from new adult members whenever they join the household or whenever members of the household become 1 a years of age. 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: Family Member HEAD X Other Adult Member of the Household - Signature, Printed Name, and Date: Family Member #3 X e -' .". .... Information Covered: inquiries may be made about lams Initiated by appDcanb1enanl " . Verillcatlon Required InlIIaII Income (all sources) AsSets (all sources) ." Child Care Expense Handicap Assistance Expense (if appncable) Medical Expense (if : appncable) Federal Preferences : Other Preferences Other (list) Dependent Deduction - Full-Time Student - HandicapJDisabled 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 HOME Program. I acknowledge that (1) A photocopy of this form is as valid as the original. (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). (3) I have the right to copy information from this file and to request correction of Information I beHeve inaccurate. ' (4) All adult household members will sign this form and cooperate with the owner in this process. Head of Household - Signature, Printed Name, and Date: (!j'" Member #2 -------------------- Other Adult Member of the Household - Signature, Printed Name, and Date: Family Member #4 X