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Authorization for the Release of Information

Rocky Mount Housing Logo.

1065 Pinehurst Drive | PO Box 4717 | Rocky Mount, NC 27803
Phone: 252.977.3141
Fax: 252.977.2587
Emergency After-Hours: 252.977.6223
Office Hours: Monday - Friday | 8:30 am - 5:00 pm

Equal housing, handicap accessible, and ADA logos.


Fields marked with * must be completed or form will not submit.


Purpose:
The Rocky Mount Housing Authority may use this authorization and the information obtained with it to administer and enforce program rules and policies.

Information covered inquires may be:

  • Child Care Expenses
  • Credit History
  • Criminal Activity
  • Educational Programs and Resources
  • Employment History
  • Family Composition
  • Identity and Marital Status
  • Job Search and Job History
  • Probation/Parole
  • Family Contributions
  • Pension & Retirement
  • Medical Information

Individuals or Organizations that may release information:
Any individual or organization including any government organizations may be asked to release information. For example, information may be requested from:

  • Banks and other Financial Institutions
  • Courts
  • Department of Social Services
  • Drug Store and Pharmacies
  • Educational Providers
  • Alcohol and Drug Service Providers
  • Law Enforcement Agencies
  • Landlords
  • Utility Companies
  • Credit  Bureaus
  • Providers of:
    • Alimony
    • Child Care
    • Child Support
  • Schools and Colleges

Computer Matching Notice and Consent:

I agree that the above organization may conduct computer-matching programs. The match will be used to verify information supplied by the family. 

The Housing Authority will be using an EIV System which is a HUD-provided lnternet-based wage and benefit tool that allows the Housing Authority to validate the accuracy of tenant-reported income from an independent source that systemically and uniformly maintains income information in computerized form for a large number of individuals.