HCV Annual Reexamination Packet

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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 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 the 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:

  • PHA- owned rental public housing
  • Turnkey III Homeownership Opportunities
  • Mutual Help Homeownership Opportunity
  • Section 23 and 19 (c) leased housing
  • Section 23 Housing Assistance payments
  • HA-owned rental Indian housing
  • Section 8 Rental Certificate
  • Sections 8 Rental Voucher
  • Section 8 Moderate Rehabilitation


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. (The 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.


Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form for the purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that Has that receive income information under this consent form cannot use it to deny, reduce or terminate assistance without first independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In addition, I must be given an opportunity to contest those determinations.


This consent form expires 15 months after signed.

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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. 1473 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 other information are being collecting by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay toward rent and utilities. Others 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 the information requested by HA, including all 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.


Original is retained by requesting organization                 ref. Handbooks 7420.7, 7420.8, & 7465.1                         form HUD-9886 (7/94)




The following items are your responsibility. Failure to obey these rules may result in your immediate termination from the Housing Choice Voucher Program.

  1. You must report any change in income and household size in writing to the Housing Authority within 2 weeks of the change.
  2. You must receive written approval from the Landlord to add any household member (other than birth, adoption or court-awarded custody) BEFORE the new member moves in.
  3. You must notify the Housing Authority when a household member no longer lives in the unit.
  4. You must supply any information, certifications and releases that HUD or the Housing Authority determines is necessary in the administration of the program. This includes information for use in a regularly scheduled interim reexamination of household income and composition.
  5. You must not violate the lease and contract in any way. Ignorance of the lease is no excuse.
  6. You must not engage in drug-related criminal activity or violent criminal activity or other criminal activity that threatens the health, safety or right to peaceful enjoyment of other residents and persons residing in the immediate vicinity of the premises.
  7. You must pay your portion of the rent to your Landlord.
  8. You must pay utility bills and provide and maintain any appliances that the owner is not required to provide under the lease.
  9. You must provide a copy of any owner eviction notice.
  10. You must provide our office and your Landlord written notice before moving. If you move prior to giving a 30 day notice, this will cause you to lose your housing assistance.
  11. You must comply with the recertification requirement. This would include any scheduled appointments, paperwork, requested documents, and the Housing Quality Standards Inspection of the unit.


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NOTICE TO APPLICANTS AND TENANTS: In order to be eligible to receive the housing assistance sought, each applicant for, or recipient of, housing assistance must be lawfully within the United States. Please read the Declarations statement carefully, sign and return to the Housing Authority office. Please feel free to consult with an immigration lawyer or other immigration expert of your choice.

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*PARENT/GUARDIAN must sign for family members under age 18. DO NOT sign child’s name.


I authorize and direct any and all listed below to release to Butler Metro Housing Authority any information needed to complete and verify my application for participation, and/or continued eligibility for assistance under the Housing Choice Voucher Program. I understand and agree that this authorization or the information obtained pursuant to its use may be given to and used by the Department of Housing and Urban Development (HUD) in administering and enforcing program rules and policies.


I also consent for HUD and or the PHA to release information from my file about my rental history to HUD, welfare department, law enforcement officials, future landlords and other government, state and public agencies. This includes eviction history, and any violation of my lease or PHA policies. I understand that this authorization cannot be used to obtain any information about me that is not pertinent to my eligibility or continued eligibility for assistance under the Housing Choice Voucher Program.


The following departments, agencies, or companies may be asked to release above information but are not limited to:


  • Former, Current or Perspective Landlords
  • Public Housing Agencies
  • Workman’s Compensation Payers
  • Job & Family Services
  • Medical & Child Care Providers
  • Child Support & Alimony Providers
  • Foster Care Providers
  • Utility Companies
  • Medical Facilities
  • Court Clerks
  • Former and Current Employers
  • Financial Institutions
  • State Unemployment Agencies
  • Social Security Administration
  • Children Services Agencies
  • School Systems
  • Retirement Systems
  • Law Enforcement Agencies
  • Credit References
  • Family Support Agencies

My Signature, as noted below, is confirmation that I do hereby authorize the Butler Metro Housing Authority to obtain or release required or requested information to or from the above sources.


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OMB Control # 2502-0581
exp. (02/28/2019)

Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants

This form is to be provided to each applicant for federally assisted housing

Instructions: Optional Contact person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization This contact information is for the purpose of identifying person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form.

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Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you.


Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law.


Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992) requires each applicant for federally assisted housing to be offered the options of providing information regarding an additional contact person or organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of 1975.


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U.S. Department of Housing and Urban Development

Office of Public and Indian Housing




Paperwork Reduction Notice: Public reporting burden for this collection of information is estimated to average 7 minutes per response. This includes the time for respondents to read the document and certify, and any recordkeeping burden. This information will be used int eh processing of a tenancy. Response to this request for information is required to receive benefits. The agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number. The OBM Number is 2577-0266, and expires 10/31/2019.



  • Public Housing (24 CFR 96)
  • Section 8 Housing Choice Voucher, including the Disaster Housing Assistance Program (24 CFR 982)
  • Section 8 Moderate Rehabilitation (24 CFR 882)
  • Project-Based Voucher (24 CFR 983)


The U.S. Department of Housing and Urban Development maintains a national repository of debts owed to Public Housings Agencies (PHAs) or Section 8 landlords and adverse information of former participants who have voluntarily or involuntarily terminated participation in one of the above-listed HUD rental assistance programs. This information is maintained within HUD’s Enterprise Income Verification (EIV) system, which is used by Public Housing Agencies (PHAs) and their management agents to verify employment and income information of program participants, as well as, to reduce administrative and rental assistance payment errors. Te EIV system is designed to assist PHAs and HUD in ensuring that families are eligible to participate in HUD rental assistance programs and determining the correct amount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUD regulations at 24 CFR 5.233.


HUD requires PHA,s which administers the above-listed rental housing programs, to report certain information at the conclusion of your participation in a HUD rental assistance program This notice provides you with information on what information the PHA is required to provide HUD, who will have access to this information, how this information is used and your rights. PHAs are required to provide this notice to all applicants and program participants and you are required to acknowledge receipt of this notice by signing page 2. Each adult household member must sign this form.


What information about you and your tenancy does HUD collect from PHA?

The following information is collected about each member of your household (family composition): full name, date of birth, and Social Security Number.


The following adverse information is collected once your participation in the housing program has ended, whether you voluntarily or involuntarily move out of an assisted unit.


  • Amount of any balance you owe the PHA or Section 8 landlord (up to $500,000) and explanation for balance owed (i.e. unpaid rent, retroactive rent (due to unreported income and/ or change in family composition) or other charges such as damages, utility charges, etc.); and
  • Whether or not you have entered into a repayment agreement for the amount that you owe the PHA; and
  • Whether or not you have defaulted on a repayment agreement; and
  • Whether or not the PHA has obtained a judgment against you; and
  • Whether or not you have filed for bankruptcy; and


The negative reason(s) for your end of participation or any negative status (i.e., abandoned unit, fraud, lease violations, criminal activity, etc.) as the end of participation date.


Who will have access to the information collected?

This information will be available to HUD employees, PHA employees, and contractors of HUD and PHAs.


How will this information be used?

PHAs will have access to this information during the time of application for rental assistance and reexamination of family income and composition for existing participants. PHAs will be able to access this information to determine a family’s suitability for initial or continued rental assistance, and avoid providing limited Federal housing assistance to families who have previously been unable to comply with HUD program requirements. If the reported information is accurate, a PHA may terminate your current rental assistance and deny your future request for HUD rental assistance, subject to PHA policy.


How long is the debt owed and termination information maintained in EIV?

Debt owed and termination information will be maintained in EIV for a period of up to ten (10) years from the end of participation date or such other period consistent with State Law.

What are my rights?

In accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to its implementation of the Federal Privacy Act of 1974 (24 CFR Part 16) you will have the following rights:

  • To have access to your records maintained by HUD, subject to 24 CFR Part 16.
  • To have an administrative review of HUD’s initial denial of your request to have access to your records maintained by HUD.
  • To have incorrect information in your record corrected upon written request.
  • To file an appeal request of an initial adverse determination on correction or amendment of record request within 20 calendar days after the issuance of the written denial.
  • To have your record disclosed to a third party upon receipt of your written and signed request.


What do I do if I dispute the debt or termination information reported about me?

If you disagree with the reported information, you would contact in writing the PHA who has reported this information about you. The PHA’s name, address, and telephone numbers are listed on the Debts Owed and Termination Report. You have a right to request and obtain a copy of this report from the PHA. Inform the PHA why you dispute the information and provide any documentation that supports your dispute. HUD’s record retention policies at 24 CFR Part 908 and 24 CFR part 982 provide that the PHA may destroy your records three years from the date your participation in the program ends. To ensure the availability of your records, disputes of the original debt or termination information must be made within three years from the end of participation date; otherwise the dept and termination information will be presumed correct. Only the PHA who reported the adverse information about you can delete or correct your record. Your filing of bankruptcy will not result in the removal of debt owed or termination information from HUD’s EIV system. However, if you have included this debt in your bankruptcy filing and/or this debt has been discharged by the bankruptcy court, your record will be updated to include the bankruptcy indication, when you provide the PHA with documentation of your bankruptcy status.


The PHA will notify you in writing of its action regarding your dispute within 30 days of receiving your written dispute. If the PHA determines that the disputed information is incorrect, the PHA will update or delete the record. If the PHA determines that the disputed information is correct, the PHA will provide an explanation as to why the information is correct.

This Notice was provided by the below-listed PHA:


(513) 868-9661 PHONE / (513) 737-8522 FAX


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Notice To Housing Choice Voucher Applicants And Tenants
Regard The Violence Against Women Act (VAWA)

A federal law that went into effect in 2013 protects individuals who are victims of domestic violence, dating violence, sexual assault, or stocking. The name of the law is the violence against women act, or “VAWH.” This notice explains your rights under VAWA.

Protections for Victims

If you are eligible for a Section 8 voucher, the housing authority cannot deny you rental assistance solely because you are a victim of the domestic violence, dating violence, sexual assault, or stalking. If you are the victim of domestic violence, dating violence, sexual assault or stalking, you cannot be terminated from the Section 8 program or evicted based on acts or threats of violence committed against you. Also, criminal acts directly related to the domestic violence, dating violence, sexual assault, or stalking that are caused by a member of your household or a guest can’t be the reason for evicting you or terminating your rental assistance if you were the victim of the abuse.

Reasons You Can Be Evicted

You can be evicted and your rental assistance can be terminated if the housing authority or your landlord can show there is an actual or imminent (immediate) threat to other tenants or employees at the property if you remain in your housing. Also, you can be evicted and your rental assistance can be terminated for serious or repeated lease violations that are not related to the domestic violence, dating violence, sexual assault, or stalking committed against you. The housing authority and your landlord cannot hold you to a more demanding set of rules then it applies to tenants who are not victims.

Removing the Abuser from the Household

Your landlord may split the lease to evict a tenant who has committed criminal acts of violence against your family members or others, while allowing the victim and other household members to stay in the assisted unit. Also, the housing authority can terminate the abuser’s Section 8 rental assistance while allowing you to continues to receive assistance. If the landlord or housing authority chooses to remove the abuser, it may not take away the remaining tenants’ rights to the unit or otherwise punish the remaining tenants. In removing the abuser from the household, your landlord must follow federal, state, and local eviction procedures.

Moving to Protect Your Safety

The housing authority may permit you to move and still keep your rental assistance, even if your current lease has not yet expired. The housing authority may require that you be current on your rent or other obligations in the housing choice voucher program. The housing authority may ask you to provide proof that you are moving because of incidences of abuse.


Proving That You Are a Victim of Domestic Violence, Dating Violence, Sexual Assault, or Stalking

The housing authority and your landlord can ask you to prove or “certify” that you are victim of domestic violence, dating violence, sexual assault, or stalking. The housing authority or your landlord must give you at least 14 business days (i.e., Saturdays, Sundays, and holidays do not count) to provide this proof. The housing authority and your landlord are free to extend the deadline. There are three ways you can prove that you are a victim:


  • Complete the certification form given to you by the housing authority or your landlord. The form will ask for you name of your abuser, the abuser’s relationship to you, the date, time, and location of the incident of iolence, and a description of the violence. You are only required to provide the name of the abuser if it is safe to provide and you know their name.
  • Provide a statement from a victim services provider, attorney, or medical professional who has helped you address incidents of domestic violence, dating violence, sexual assault, or stalking. The professional must state that he or she believes that the incidents of abuse are real. Both you and the professional must sign the statement, and both of you must state that you are signing “under penalty of perjury.”
  • Provide a police or court record, such as a protective order.


If you fail to provide one of these documents within the required time, the landlord may evict you, and the housing authority may terminate your rental assistance.



The housing authority and your landlord must keep confidential any information you provide about the violence against you, unless:


  • You give written permission to the housing authority or your landlord to release the information.
  • Your landlords needs to use the information in an eviction proceeding, such as to evict your abuser.
  • A law requires the housing authority or your landlord to release the information.


If release of the information would your safety at risk, you should inform the housing authority and your landlord.


VAWA and Other Laws

VAWA does not limit the housing authority’s or your landlord’s duty to honor court orders about access to or control of the property. This includes orders issued to protect a victim and orders dividing property among household members in cases where a family breaks up.


VAWA does not replace any federal, state, or local law that provides greater protection for victims of domestic violence, dating violence, sexual assault, or stalking.


For Additional Information

If you have any questions regarding VAWA, please contact Domestic Violence Services at (530) 283-5675 or 1-888-504-5102.


For help and advice on escaping an abusive relationship, call the National Domestic Violence Hotline at 1-800-799-SAFE (7233) or 1-800-787-3224 (TTY).



For purposes of determining whether a tenant may be covered by VAWA, the following list of definitions applies:

VAWA defines domestic violence to include felony or misdemeanor crimes of violence committed by any of the following:


  • A current or former spouse of the victim
  • A person with whom the victim shares a child in common
  • A person who is cohabitating with or has cohabitated with the victim as a spouse
  • A person similarly situated to a spouse of the victim under the domestic or family violence laws of the jurisdiction receiving grant monies
  • Any other person against an adult or youth victim who is protected from that person’s acts under the domestic or family violence laws of the jurisdiction


VAWA defines dating violence as violence committed by a person (1) who is or has been in a social relationship of a romantic or intimate nature with the victim AND (2) where the existence of such a relationship shall be determined based on a consideration of the following factors:


  • The length of the relationship
  • The type of relationship
  • The frequency of interaction between the person involved in the relationship


VAWA defines sexual assault as “any nonconsensual act proscribed by Federal, tribal, or State law, including when the victim lacks capacity to consent” (42 U.S. C 13925(a)).


VAWA defines stalking as (A)(i) to follow, pursue, or repeatedly commit acts with the intent to kill, injure, harass, or intimidate another person OR (ii) to place under surveillance with the intent to kill, injure, harass, or intimidate another person AND (B) in the course of; or as a result of, such following, pursuit, surveillance, or repeatedly committed acts, to place a person in reasonable fear of the doth of, or serious bodily injury to, or to cause substantial emotional harm to (i) that person, (ii) a member of the immediate family of that person, or (iii) the spouse or intimate partner of that person.


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