Information Covered: Inquiries may be made about items including:
Income (all sources including dependent income), Assets (all sources), Child Support, Rental Amount.
Instructions to Applicant: Your signature on this Eligibility Release, and the signatures of each member of your household who is 18 years of age or older, authorizes the city of Aurora or any of its duly authorized representatives to obtain information from a third party regarding your eligibility and continued participation in the Emergency Housing Assistance Program (COVID-19).
Privacy Act Notice Statement: The City of Aurora requires the collection of the information listed in this form to determine an applicant’s eligibility for the Program. This information will be used to establish the level of benefits for which the applicant is eligible and to verify the accuracy of the information furnished. information received from an applicant or as a result of verifying the applicant’s eligibility may be released to appropriate Federal, State, and Local government and local agencies, or when relevant, to civil, criminal, or regulatory investigators, and to prosecutors, Failure to provide any information may result in delay or rejection of your eligibility approval. Subrecipient is authorized to ask for this information under the National Affordable Housing Act of 1990.
NOTE: THIS GENERAL CONSENT MAY NOT BE USED TO REQUEST A COPY OF A TAX RETURN.
I authorize the above-named Nonprofit, State or Local Government or Vendor to obtain information about me and my household that is pertinent to determining my eligibility for participation in the Program, I acknowledge that:
(1) A photocopy of this form is valid as the original; AND
(2) My printed name will act in lieu of a written signature for the purposes of this form: AND
(3) I have the right to review information received using this form; AND
(4) I have the right to a copy of information provided to the Subrecipient and to request correction of any information I believe to be inaccurate; AND
(5) All adult household members will sign this form and cooperate with the subrecipient in the eligibility verification process.
WARNING: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government.