Consent for Release of Information

Creative Housing requests the cooperation of Program Participants so we can best provide and sustain a safe, affordable, and inclusive living environment. Authorization granted is valid for only the duration of participation in Creative Housing programs and can be revoked by Participant in writing at any time.

Creative Housing works with authorized Contacts on behalf of Program Participants to ensure program requirements are met for stable, affordable housing. Consenting to authorization facilitates meeting program requirements and preventing the termination of housing benefits.

First Name

Last Name

Address Number

Street Name

Apt. No., etc.

City

State

Zip

SSN

Applicant/Tenant
resides in a Creative Housing Home (CHH)
is a Private Market Rent Subsidy (PMRS) client

First Name

Last Name

Email

Business Phone

Cell Phone

Other Contact Method

Communications related to housing needs
Authorization Granted

Communications related to income
Authorization Granted

Communications related to payments due
Authorization Granted

Authorization for permission to enter
Authorization Granted

Other Authorization Granted

Check the box if there is no Nisonger Specialist
Not Applicable

First Name

Last Name

Email

Business Phone

Cell Phone

Other Contact Method

Communications related to housing needs
Authorization Granted

Communications related to income
Authorization Granted

Communications related to payments due
Authorization Granted

Authorization for permission to enter
Authorization Granted

Other Authorization Granted

First Name

Last Name

Email

Business Phone

Cell Phone

Other Contact Method

Communications related to housing needs
Authorization Granted

Communications related to income
Authorization Granted

Communications related to payments due
Authorization Granted

Authorization for permission to enter
Authorization Granted

Other Authorization Granted

Check the box if there is no Provider - Secondary
Not Applicable

First Name

Last Name

Email

Business Phone

Cell Phone

Other Contact Method

Communications related to housing needs
Authorization Granted

Communications related to income
Authorization Granted

Communications related to payments due
Authorization Granted

Authorization for permission to enter
Authorization Granted

Other Authorization Granted

Check the box if there is no Payee
Not Applicable

First Name

Last Name

Email

Business Phone

Cell Phone

Other Contact Method

Communications related to housing needs
Authorization Granted

Communications related to income
Authorization Granted

Communications related to payments due
Authorization Granted

Authorization for permission to enter
Authorization Granted

Other Authorization Granted

Check the box if there is no Other Money Management Support
Not Applicable

First Name

Last Name

Email

Business Phone

Cell Phone

Other Contact Method

Communications related to housing needs
Authorization Granted

Communications related to income
Authorization Granted

Communications related to payments due
Authorization Granted

Authorization for permission to enter
Authorization Granted

Other Authorization Granted

Check the box if there is no Advocate
Not Applicable

First Name

Last Name

Email

Business Phone

Cell Phone

Other Contact Method

Communications related to housing needs
Authorization Granted

Communications related to income
Authorization Granted

Communications related to payments due
Authorization Granted

Authorization for permission to enter
Authorization Granted

Other Authorization Granted

Check the box if there is no Advocate
Not Applicable

First Name

Last Name

Email

Business Phone

Cell Phone

Other Contact Method

Communications related to housing needs
Authorization Granted

Communications related to income
Authorization Granted

Communications related to payments due
Authorization Granted

Authorization for permission to enter
Authorization Granted

Other Authorization Granted

I consent to allow Creative Housing to communicate with the parties as authorized on this form for the purpose of meeting housing program requirements.

Name of person filling out this form

Signature

Signor is the Program Participant
Signor is the Guardian of the Person Estate for the Program Participant and their contact information is:

First Name

Last Name

Email

Business Phone

Cell Phone

Other Contact Method

First Name

Last Name

Email

Business Phone

Cell Phone

Other Contact Method