"LIHTC Demographic Data Release Consent Form"

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LIHTC DEMOGRAPHIC DATA RELEASE CONSENT FORM
We, the adult members of the household living in the property at the address below, do hereby give consent to the
owner and the manager of that property to share with offices of the state and federal governments, and their
designated subcontractors and agents, demographic and other information about my household, myself, and members
of my household.
The information is intended for use in compliance with the reporting requirements regarding the characteristics of
households living in each Low Income Housing Tax Credit property, including race, income, age, ethnicity, family
composition, use of Section 8 and other rental assistance, and monthly rental payments, pursuant to the Housing and
Economic Recovery Act of 2008. All information obtained through this Consent Form shall be protected and shall remain
confidential to the extent required by federal and state privacy laws and regulations.
A copy of this Consent Form has the same authority as the original. Consent forms signed separately by different adult
members of the household will have the same effect as one consent form signed by all adult members of the household.
Property Name: _____________________________________________
Address: _____________________________________________
Date: ____________
Signature: ______________________________________
Adult Household Member Name [please print]: ______________________________________
Address: ______________________________________________________________________
Date: ____________
Signature: ______________________________________
Additional Adult Household Member [please print]: ___________________________________
Address: ______________________________________________________________________
Date: ____________
Signature: ______________________________________
Additional Adult Household Member [please print]: ___________________________________
Address: ______________________________________________________________________
I, having custody of the minor children listed below who are members of the household living in the property at the
address above, do hereby give consent to the owner and the manager of that property to share with offices of the state
and federal governments, and their designated subcontractors and agents, demographic and other information
(described above) about those minor children.
Child’s Name: ______________________________________
Child’s Name: ______________________________________
Child’s Name: ______________________________________
Date: ____________
Signature: ______________________________________
Adult Household Member Name [please print]: ______________________________________
Address: ______________________________________________________________________
LIHTC DEMOGRAPHIC DATA RELEASE CONSENT FORM
We, the adult members of the household living in the property at the address below, do hereby give consent to the
owner and the manager of that property to share with offices of the state and federal governments, and their
designated subcontractors and agents, demographic and other information about my household, myself, and members
of my household.
The information is intended for use in compliance with the reporting requirements regarding the characteristics of
households living in each Low Income Housing Tax Credit property, including race, income, age, ethnicity, family
composition, use of Section 8 and other rental assistance, and monthly rental payments, pursuant to the Housing and
Economic Recovery Act of 2008. All information obtained through this Consent Form shall be protected and shall remain
confidential to the extent required by federal and state privacy laws and regulations.
A copy of this Consent Form has the same authority as the original. Consent forms signed separately by different adult
members of the household will have the same effect as one consent form signed by all adult members of the household.
Property Name: _____________________________________________
Address: _____________________________________________
Date: ____________
Signature: ______________________________________
Adult Household Member Name [please print]: ______________________________________
Address: ______________________________________________________________________
Date: ____________
Signature: ______________________________________
Additional Adult Household Member [please print]: ___________________________________
Address: ______________________________________________________________________
Date: ____________
Signature: ______________________________________
Additional Adult Household Member [please print]: ___________________________________
Address: ______________________________________________________________________
I, having custody of the minor children listed below who are members of the household living in the property at the
address above, do hereby give consent to the owner and the manager of that property to share with offices of the state
and federal governments, and their designated subcontractors and agents, demographic and other information
(described above) about those minor children.
Child’s Name: ______________________________________
Child’s Name: ______________________________________
Child’s Name: ______________________________________
Date: ____________
Signature: ______________________________________
Adult Household Member Name [please print]: ______________________________________
Address: ______________________________________________________________________
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