I authorize and direct the persons, agencies or organizations listed on this Authorization to release and exchange information with Prairie Harvest Mental Health as needed, for the purpose of determining my qualifications for housing. I understand and agree that this authorization or the information obtained with its use may be given to and used by Prairie Harvest Mental Health in administering and enforcing program rules and policies. I also consent for Prairie Harvest Mental Health to release information from my file about my rental history to HUD, credit bureaus, collection agencies, landlords and other PHAs. I understand that, depending on program policies and requirements, previous or current information regarding my household or me may be exchanged. I understand that this authorization cannot be used to obtain any information about me that is not pertinent qualifying for housing. Verifications, inquiries and exchange of information that may be requested, include but are not limited to: Identity and Marital Status, Employment, Income and Assets, Residences and Rental Activity, Credit and Criminal Activity. PERSONS, GROUPS OR INDIVIDUALS THAT MAY BE ASKED TO SUPPLY INFORMATION Previous landlords (including Public Housing Agencies), Past and Present Employers, Veterans Administration, Welfare Agencies, Retirement Systems, Court and Post Offices, State Unemployment Agencies, Banks & other Financial Institutions, Schools and Colleges, Social Security Administration, Credit Providers and Credit Bureaus, Law Enforcement Agencies, Medical and Child Care Providers, Utility Companies, and Support and Alimony Providers. CONDITIONS I agree that a photocopy of this authorization may be used for the purposes stated above. The original or an electronic version of this authorization is on file with Prairie Harvest Mental Health and will stay in effect for fifteen months from the date signed. I understand I have a right to review my file and correct any information that I can prove is incorrect. SIGNATURES X Head of Household (Print Name) Date X Guardian (Print Name) Date X_ _ Adult Member (Print Name) Date
I authorize and direct the persons, agencies or organizations listed on this Authorization to release and exchange information with Prairie Harvest Mental Health as needed, for the purpose of determining my qualifications for housing. I understand and agree that this authorization or the information obtained with its use may be given to and used by Prairie Harvest Mental Health in administering and enforcing program rules and policies. I also consent for Prairie Harvest Mental Health to release information from my file about my rental history to HUD, credit bureaus, collection agencies, landlords and other PHAs. I understand that, depending on program policies and requirements, previous or current information regarding my household or me may be exchanged. I understand that this authorization cannot be used to obtain any information about me that is not pertinent qualifying for housing. Verifications, inquiries and exchange of information that may be requested, include but are not limited to: Identity and Marital Status, Employment, Income and Assets, Residences and Rental Activity, Credit and Criminal Activity. PERSONS, GROUPS OR INDIVIDUALS THAT MAY BE ASKED TO SUPPLY INFORMATION Previous landlords (including Public Housing Agencies), Past and Present Employers, Veterans Administration, Welfare Agencies, Retirement Systems, Court and Post Offices, State Unemployment Agencies, Banks & other Financial Institutions, Schools and Colleges, Social Security Administration, Credit Providers and Credit Bureaus, Law Enforcement Agencies, Medical and Child Care Providers, Utility Companies, and Support and Alimony Providers. CONDITIONS I agree that a photocopy of this authorization may be used for the purposes stated above. The original or an electronic version of this authorization is on file with Prairie Harvest Mental Health and will stay in effect for fifteen months from the date signed. I understand I have a right to review my file and correct any information that I can prove is incorrect. SIGNATURES X Head of Household (Print Name) Date X Guardian (Print Name) Date X_ _ Adult Member (Print Name) Date
Prairie-Lodge-PHMH-Occupancy-Application.docx