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INDIAN RIVER COUNTY NEIGHBORHOOD STABILIZATION PROGRAM 3 IMPLEMENTED BY INDIAN RIVER HABITAT FOR HUMANITY 4568 N . US Highway 1 , Vero Beach , FL 32967 ��R�u� {T° (772) 562 =9860 APPLICANT/TENANT RELEASE AND CONSENT I/We , , the undersigned hereby authorize the below listed groups and individuals, to release without liability, information regarding my/our employment, income, and/or assets to Indian River County and Indian River Habitat for Humanity for purposes of verifying information provided as part of my/our request for assistance under the Neighborhood Stabilization Program 3 . INFORMATION COVERED . I/We understand that previous or current information regarding me/us may be needed . Verifications and inquiries that may be requested include , but are not limited to: personal identity, employment, income , and assets , and medical or childcare allowances. I/We understand that this authorization cannot be used to obtain any information about me/us that is not pertinent to my/our eligibility for the Neighborhood Stabilization Program 3 . GROUPS OR INDIVIDUALS THAT MAY BE ASKED : The groups or individuals that may be asked to release the above information include , but are not limited to : Past and Present Employers Welfare Agencies Veterans Administration Previous Landlords ( including Public State Unemployment Agencies Retirement Systems Housing Agencies) Social Security Admin . Banks and other Financial Support and Alimony Providers Credit Agencies Institutions CONDITIONS : I /We agree that a photocopy of this authorization may be used for the purposes stated above . THE ORIGINAL OF THIS AUTHORIZATION IS ON FILE AND WILL STAY IN EFFECT FOR ONE YEAR AND ONE MONTH FROM THE DATE SIGNED. I/We understand that I/We have a right to review this file and correct any information therein that I/We find to be incorrect or outdated . SIGNATURES . Head of Household (print name) Date Spouse (print name) Date Adult Member ( print name) Date Adult Member ( print name) Date NOTE : THIS GENERAL CONSENT MAY NOT BE USED TO REQUEST A COPY OF A TAX RETURN . IFA COPY OF A TAX RETURN IS NEEDED , IRS FORM 4506 , " REQUEST FOR COPY OF TAX FORM" MUST BE PREPARED AND SIGNED SEPARATELY.