HUD Form 9886 (reissued 07/2017)

Authorization for the Release of Information and Privacy Act Notice

Required from each adult household member at admission and recertification under Section 904 of the Stewart B. McKinney Homeless Assistance Amendments Act of 1988, 42 U.S.C. Sec. 3543, and 24 C.F.R. Sec. 5.230.

Form 50059 Owner Certification Form 5380 VAWA Notice Form 5382 VAWA Certification Official HUD PDF

Validity period

This authorization expires 15 months after the date of signature. A new HUD-9886 must be signed at each annual recertification. The form authorizes disclosure of information by current and former employers, financial institutions, the IRS, the Social Security Administration, and prior landlords to HUD and the Owner of the assisted property.

Authorization

I authorize the U.S. Department of Housing and Urban Development (HUD) and the Owner (and the Owner's employees and contractors) of the property listed on the assistance application or recertification document to obtain information about my income, assets, and household composition from the sources listed below. The information will be used to determine my eligibility for HUD-assisted housing and the amount of any rent subsidy or rental assistance I am entitled to receive.

Information to be released

The following information may be released by the sources listed below to HUD or to the Owner:

  • Current and past employment, wages, and earnings, including pay stubs, W-2 forms, 1099 forms, and IRS tax transcripts.
  • Social Security and Supplemental Security Income payments, retirement and disability benefits.
  • Unemployment compensation and workers' compensation.
  • Veteran's benefits.
  • Welfare and Temporary Assistance for Needy Families payments.
  • Bank account balances, certificate-of-deposit balances, brokerage statements, and any other asset-value statements.
  • Pension and retirement-fund balances and distributions.
  • Records of any other income, assets, or property held by me or on my behalf.
  • Records of household composition: marriage records, birth certificates, divorce decrees, custody orders.
  • Citizenship or immigration status records relevant to eligibility determination.
  • Records of any prior tenancy: rent payment history, lease violations, eviction filings.

Sources

The information may be released by any of the following sources upon presentation of this signed authorization:

  • Current and former employers (private and public).
  • State agencies administering unemployment compensation, welfare, child support, and vital records.
  • The Social Security Administration.
  • The Internal Revenue Service (for income verification purposes only via the HUD EIV system or IRS Form 4506-T).
  • The U.S. Department of Veterans Affairs.
  • Banks, credit unions, brokerages, and other financial institutions.
  • Pension plan administrators, retirement plan administrators, and life-insurance companies.
  • Prior landlords, property managers, and real-estate agents.
  • Federal, state, and local agencies maintaining records that may verify the above.

EIV (Enterprise Income Verification) consent

By signing this form, I consent to HUD's use of the Enterprise Income Verification (EIV) system to verify my income directly with the SSA, IRS, and state workforce agencies. EIV reports are confidential and may be disclosed only to HUD and the Owner; the household is entitled to see and contest the data per 24 C.F.R. Sec. 5.236.

Privacy Act notice (5 U.S.C. Sec. 552a)

The collection of this information is authorized by Section 904 of the Stewart B. McKinney Homeless Assistance Amendments Act of 1988, 42 U.S.C. Sec. 3543. Information collected on this form is mandatory; failure to provide it will result in denial or termination of housing assistance.

The information you provide may be disclosed to other government agencies for verification and to law enforcement when authorized by routine use. Records are maintained in System of Records HUD/CHCO-1, "Tenant and Owner Information System," 80 Fed. Reg. 81837 (Dec. 31, 2015). You have the right to inspect and correct your records under the Privacy Act; contact the HUD Privacy Office, 451 Seventh Street SW, Washington, DC 20410.

Signatures (one per adult household member)

Printed name:  

Social Security Number (last 4 digits): XXX-XX-  

Date of birth:  

Relationship to head of household:  

Signature:  

Date signed:  

Owner or representative attests that this form was signed in the presence of an Owner representative or returned via secure channel and that the household member's identity was verified by photo ID:

Owner representative name:  

Signature and date:  

Penalties for false statements

Knowingly making a false or misleading statement on this form is punishable under 18 U.S.C. Sec. 1001 by fine and/or imprisonment for up to 5 years. HUD may also impose administrative penalties including loss of assistance and debarment from federal housing programs.

This is a plain-language reference copy of HUD Form 9886 as reissued 07/2017 (OMB 2502-0204). The official PDF from HUD controls in any conflict; the original signed form must be retained in the tenant file for the longer of (a) three years after the household leaves the property or (b) the period required by the project's HAP contract. Rentari.ai is not a HUD compliance vendor.

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