Ponca Housing Opportunities Program Authorization for Release of Information

Applicant Name

Co-Applicant/Adult Household Member

PURPOSE

I/We authorize NPHA to obtain and verify information reasonably necessary to process the Fair Market Rental Program application, determine eligibility and ability to pay, conduct permitted screening, select applicants, and administer the tenancy when applicable.

INFORMATION THAT MAY BE VERIFIED

Employment, job status, dates, wages and salary.
Other recurring income reported by the applicant.
Current and prior rental history, payment history, lease compliance, balances, evictions and property damage.
Current or prior NPHA tenancy and NPHA debt.
Credit/consumer-report information.
Criminal/background information.
Ponca tribal enrollment information for eligibility verification.
Other information reasonably necessary to verify application information.

AUTHORIZED SOURCES

Employers and income sources.
Current and former landlords/property managers.
Government agencies or benefit providers.
Consumer reporting agencies and screening providers.
NPHA records and departments.
Ponca Tribe of Nebraska or authorized enrollment office.
Other sources identified by the applicant.

This is a checkbox.

AUTHORIZATION PERIOD

This authorization is effective from the date signed and may be used during application and selection. If the applicant becomes a tenant, it may be used for permitted verification related to administration of the tenancy, unless revoked or a new authorization is required.

SIGNATURES

Date

Month

Day

Year

Applicant Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Applicant Social Security Number

Your Feedback Matters

We value your feedback and inquiries and look forward to assisting you. Let’s work together to create brighter futures for Native American families.