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Please read each item carefully. The answers you give will be used to determine your eligibility. All information requested on this application must be provided to be considered for assistance. However, this application is not a guarantee of assistance. Applications are reviewed and assistance is provided based on factors such as, but not limited to funding, ability to positively resolve a situation, indications the crisis will not reoccur; and use of alternate funding sourced if available.

I certify the above information is true and correct. My application for assistance is because of an immediate need for help at this time. I authorize the release to Ho-Chunk Housing and Community Development Agency for any and all information needed to complete and verify my application. I understand any misrepresentation or falsification of information will make me ineligible for program assistance, and will result in paying the program back in full.

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WHEREAS, I________________, am an enrolled Tribal Member of the Ho-Chunk Nation entitled to receipt of Per Capita Disbursements pursuant to the Nation's Per Capita distribution Ordinance in accordance with Section 1 l(b)(3) of the Indian Gaming Regulatory Act, 23 U.S.C. Section 2710(b)(3); and, 

WHEREAS, the Ho-Chunk Nation has adopted the Claims against Per Capita Ordinance for matter inclusive of debts owed to the Nation, at Section 103(a); and,

WHEREAS, the Ho-Chunk Housing & Community Development Agency (HHCDA) and I entered into a lease on ________, 

for the property located at:_________.

I HEREBY CONSENT to the filing of an administrative Claim against Per Capita commencing with the anticipated date of _______, simultaneously effecting any prior unclaimed per capita distributions: and continuing for all future distribution in the amount of $175.00x 4, equalling $700.00

ANY MONIES remaining in my per capita distribution after this and all other legitimate claims against my per capita distribution shall be mailed directly to me at the address I provide to the Enrollment Dept.

This form will only be used if I am found to be in non-compliance of the HHCDA Rental Assistance Policy, or if I have been granted] the assistance and later found to have falsified my application.

I/we, the undersigned, with this, authorize the HO-CHUNK HOUSING & COMMUNITY DEVELOPMENT AGENCY and their agents to obtain any information, necessary, to process the HUD housing application. This information may be obtained from the following sources, any of the programs of the HO-CHUNK NATION, federal, state and local governments and any of their agencies and representatives, law enforcement agencies, financial institutions and current and prior landlords. This list is not all-inclusive and may include any additional agency. Government or private source as deemed necessary by the HO-CHUNK HOUSING & COMMUNITY DEVELOPMENT AGENCY and/or their agents.

I/We, the undersigned, with this, release the HO-CHUNK HOUSING & COMMUNITY DEVELOPMENT AGENCY and/or their agents any requested information from the following agencies: federal, state and local governments law enforcement agencies, financial institutions and current and prior landlords.

The information requested maybe given by fax, telephone or in writing. This release is valid for one year from the date of the applicant's signature. This release is valid if photocopied and does not have to have and original signature.

I/we, have read the terms and conditions of this AUTHORIZATION FOR THE RELEASE OF INFORMATION and with this, give consent for the release of any requested information.

The U.S. Department of Housing and Urban Development (HUD) will be collecting information you gave to the Ho-Chunk Housing & Community Development Agency at application or reexamination. HUD will collect the information on Form HUD 50058. The data it will collect include name, sex, birth date, Social Security Number (SSN), Income (by source), assets, certain deductible expenses, and rental payment.

The Privacy Act of 1974, as amended, requires us to tell about this. We also are required to tell you what HUD will do with the information.

HUD may give the information to manage and monitor HUD assisted housing programs. It also may verify whether the information is accurate and complete by doing a computer match.

HUD may give the information to Federal, State, and local agencies when it will be used for civil, criminal or regulatory investigations and prosecutions. HUD also may make summaries of resident data available to the public. Other than these uses, HUD will not release the information outside HUD, except as permitted or required by law.

The Housing and Community Development Act of 1987, 42 U.S.C. 3543 requires applicant and residents to give the Ho-Chunk Housing & Community Development Agency the SSN(s) of household members at least six (6) years old. If you are an applicant and you have been issued or use SSN(s) and you do not give them to the Ho-Chunk Housing & Community Development Agency, Ho-Chunk Housing & Community Development Agency is required to reject your application for housing assistance. If you are receiving housing assistance and you have been issued or use SSN(s) and you do not give them to the Ho-Chunk Housing & Community
Development Agency, the Ho-Chunk Housing & Community Development Agency is required to evict your family or withdraw your housing assistance.

The U.S. Housing Act of 1937, as amended 42 U.S.C. 1437 et. Seq., and the Housing and Community Development Act of 1987, P.L. 97 - 35, 85 stat., 348,408 require applicants and residents to provide the other information listed in the first paragraph to the Ho-Chunk Housing & Community Development Agency. If you are an applicant and you fail to give the Ho-Chunk Housing & Community Development Agency this information, the Ho-Chunk Housing & Community Development Agency may have to reject your application or delay acting on it. If you are receiving housing assistance and you do not give the Ho-Chunk Housing & Community Development Agency may have to evict or withdraw your housing assistance.

I have read and fully understand the Federal Privacy Act Statement:

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: (I) 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 HUD and 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 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
Section 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. (This 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 HU D'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.

Signatures:

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. 1437 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 participants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay toward rent and utilities. Other 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 of the information requested by the HA, including all Social Security Numbers you, and all other household members age six years and older, have and use. Giving the 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 mor, 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, aga the officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use.