Authorization For Release of Credit/Criminal Information Name * First Name Last Name Social Security Number * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Sign * * I consent to allow the Department of Housing & Urban Development (HUD) or Mid-East Regional Housing Authority to request and obtain credit/criminal information from all sources for the purpose of verifying my eligibility under HUD’s assisted housing programs and/or employment. I understand that information received under the consent form must be treated confidential in accordance with the Federal Privacy Act. In addition, I understand that I must be given an opportunity to contest any adverse determinations. Thank you!
