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INDIAN RIVER COUNTY NEIGHBORHOOD STABILIZATION PROGRAM 3 IMPLEMENTED BY INDIAN RIVER HABITAT FOR HUMANITY _ .1 4568 N . US Highway 1 , Vero Beach , FL 32967 EQUAL HOUSING Rte' ( 772 ) 562 =9860 OPPORTUNITY APPLICANT/TENANT RELEASE AND CONSENT I /We , the undersigned hereby authorize the below listed groups and individuals , to release without liability , information regarding mjr/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that I /We have a right to review this file and correct any information therein that I /We find to be incorrect or outdated .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.