Authorization for Release of Information

CONSENT: I authorize and direct any federal, state or local agency, organization, business or individual to release information to representatives of King Park Development Corp, which may be necessary for me to qualify to receive federal assistance. I understand and agree that this authorization or the information obtained with its use may be given to and used to administer and enforce program rules and policies in compliance with HUD, IHCDA, CDBG and HOME Program or other governmental housing program guidelines. I also consent for the manager to release information from my file to the Indianapolis Housing Partnership (INHP) for pre-screening purposes.

INFORMATION COVERED: I understand that previous or current information regarding myself or my household may be needed. Verification and inquiries that may be requested include but are not limited to:

Identity and marital status
Property ownership status

Employment income, assets, pension or benefits
Credit activity

GROUPS OR INDIVIDUALS THAT MAY BE ASKED: The groups of individuals that may be asked to release the above information (depending on the program requirements) include but are not limited to:

Additional lien holders
Welfare or supportive service agencies
Social Security Administration
State Employment Bureaus and Services
Banks and other financial institutions
Children Services

Past and present employers
Courts and post offices
Schools and Colleges
Child Support/alimony providers
Retirement systems
Utility companies

CONDITIONS: I agree that a photocopy or facsimile of this authorization may be used for the purposes stated above. The original of this authorization is on file in the Renew Indianapolis Inc. office and will stay in effect for one year and six months from the date signed.

TO BE SIGNED AND COMPLETED BY ALL HOUSEHOLD MEMBERS 18 AND OVER: