PRIVACY ACT STATEMENT

**Authority**: The U.S. Department of Housing and Urban Development
(HUD) is authorized to collect this information pursuant to the Housing
and Community Development Act of 1987, 42 U.S.C. 3543, the U.S. Housing
Act of 1937, as amended, 42 U.S.C. 1437 et seq., and the Housing and
Community Development Act of 1981, P.L. 97-35, 85 stat., 34, 408.

**Intended Use of Information:** The U.S. Department of Housing and
Urban Development (HUD) requires that the
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herein referred to as the Agency, collect income and housing information
for the purpose of determining relocation assistance in accordance with
the Uniform Relocation Assistance and Real Property Acquisition Policies
Act of 1970 (URA), as amended, and if applicable, with section 104(d) of
the Housing and Community Development Act of 1974. The data it will
collect include name, sex, birth date, Social Security Number (SSN),
income (by source), assets, certain deductible expenses, rental payment,
utility costs, and if voluntarily provided, information related to
mobility and other special needs.

**Routine Uses of Information:** HUD will use the information to manage
and monitor HUD-assisted housing programs. It also may verify whether
the information is accurate and complete by doing a computer match.

HUD may give the information to Federal, State, and local agencies when
it will be used for civil, criminal or regulatory investigations and
prosecutions. HUD also may make summaries of resident data available to
the public. Other than these uses, HUD will not release the information
outside HUD, except as permitted or required by law.

**Penalty:** The Housing and Community Development Act of 1987, 42
U.S.C. 3543 requires applicants and residents to give the Agency the
SSNs of household members at least six (6) years old. If you are an
applicant and you have been issued or use SSN(s) and you do not give
them to the Agency, or refuse to disclose other income-related
information, the Agency may elect to disregard the income of the
household in calculating a displaced residential person's replacement
housing assistance. If you are receiving housing assistance and you have
been issued or use SSN(s), you must disclose such assistance in order to
avoid a duplication of payment so as to ensure the Agency is in
compliance with the requirement to avoid fraud, waste and abuse.

The U.S. Housing Act of 1937, as amended, 42 U.S.C. 1437 et. seq., and
the Housing and Community Development Act of 1981, P.L. 97-35, 85 stat.,
348, 408 require applicants and residents to provide the other
information (listed in the second paragraph) to the Agency. If you are
an applicant and you fail to give the Agency this information, the
Agency may have to reject your claim for assistance or delay acting on
it. If you are receiving housing assistance and you do not advise the
Agency of such assistance, the housing assistance you now receive may be
terminated to avoid a duplication of payment and to ensure that the
Agency is in compliance with the requirement to avoid fraud, waste and
abuse.

SIGNATURE: I read and understand the Privacy Act Statement on
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> (date)

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Head of Household or Spouse