INFORMATION BEING REQUESTED

(Owners: Fill in here the information requested. Consult Appendix 6-C of this handbook for examples of relevant information that owners may request from third parties in verifying several types of income and information and household characteristics. This list of information is not meant to be all-inclusive. Owners may add other information as long as any additional information is relevant to determining the individual’s eligibility for assistance or level of benefits. This instruction does not have to appear on an individual consent.)

Name and Title of Person Firm/Organization Supplying the Information Signature Date

Name and Title of Person Supplying the Information

========================================================================

HUD Occupancy Handbook Appendix 6-C: Guidance About Types of Information to Request When Verifying Eligibility and Income

6/07

3

4350.3 REV-1

Appendix 6-A

========================================================================

RELEASE: I hereby authorize the release of the requested information. Information obtained under this consent is limited to information that is no older than 12 months. There are circumstances that would require the owner to verify information that is up to 5 years old, which would be authorized by me on a separate consent attached to a copy of this consent.

Signature Date

Note to Applicant/Tenant: You do not have to sign this form if either the requesting organization or the organization supplying the information is left blank.

========================================================================