Page 11 - TBRA_Intake

TEXAS DEPARTMENT OF HOUSING AND COMMUNITY AFFAIRS
RELEASE AND CONSENT FORM

I. THIS SECTION TO BE COMPLETED BY ADMINISTRATOR/OWNER/MANAGEMENT

Administrator/Owner/Management Name: TDHCA Number:

Contact Name: Contact Title:

Address: Phone:

Email Address: Fax:

II. THIS SECTION TO BE COMPLETED BY APPLICANT

Applicant/Resident Name:

I/We _____________________________________________________, the undersigned hereby authorize all persons or
companies in the categories listed below to release information regarding employment, income and/or assets for purposes of
verifying information on my/our application for participation in a Texas Department of Housing and Community Affair’s
(TDHCA) Affordable Housing Program. I/we authorize release of information without liability to the
administrator/owner/management listed above, and/or the Texas Department of Housing and Community Affairs and/or the
Department’s service provider.

INFORMATION COVERED

I/We understand that previous or current information regarding me/us may be needed. Verifications and inquires that may
be requested include, but are not limited to: personal identity, student status, employment, income, assets, and medical or
child care allowances. I/We understand that this authorization cannot be used to obtain information about me/us that is not
pertinent to my eligibility for and continued participation in a TDHCA Affordable Housing Program.

GROUPS OR INDIVIDUALS THAT MAY BE ASKED

The groups or individuals that may be asked to release the above information include, but are not limited to:

Past and Present Employers Welfare Agencies Veterans Administrations

Support and Alimony Providers State Unemployment Agencies Retirement Systems
Educational Institutions Social Security Administration Medical and Child Care Providers

Bank and other Financial Institutions Utility Providers Previous Landlords
Insurance Carrier
Public Housing Agencies Appraisal Districts

III. APPLICANT CERTIFICATION

I/We agree that a photocopy of this authorization may be used for the purposes stated above. The original of this
authorization is on file and will stay in effect for a year and one month from the date signed. I/We understand I/We have
a right to review this file and correct any information that is incorrect.

_____________________________ ____________________________ _______________________

Applicant/Resident Printed Name Signature Date

_____________________________ ____________________________ _______________________

Co-Applicant/Resident Printed Name Signature Date

_____________________________ ____________________________ _______________________

Adult Member Printed Name Signature Date

_____________________________ ____________________________ _______________________

Adult Member Printed Name Signature Date

NOTE: THIS GENERAL CONSENT MAY NOT BE USED TO REQUEST A COPY OF A TAX RETURN. IF A COPY OF A TAX RETURN IS
NEEDED, IRS FORM 4506, “REQUEST FOR COPY OF A TAX FORM” MUST BE PREPARED AND SIGNED SEPARATELY.

TDHCA Page 1 of 1 Revised May 2010