Metro Interfaith HUD Housing Counseling Intake Form

Metro Interfaith Housing Counseling Agency, 21 New Street, Binghamton, NY 13903
Office Tel. (607) 723-0723, Fax:(607) 722-8912



Date Of Application
*E-mail Address
Name
Present Address
City
State
Zip Code
Home Telephone Number
Work Telephone Number
Social Security Number
Date Of Birth
Annual Median Income
Number Of Household Members
Number Of Children
Reason For Housing Counseling

* Required Field


Confidentiality & CARS Disclosure Statement

HUD (Housing and Urban Development) will follow strict rules to protect your confidentiality. The personal data collected, such as name and address, are protected by the Privacy Act,

You will never be named in any reports. Although your responses may be looked at individually by HUD, or contractors hired by HUD to collect and analyze the data, your name will not be reported.

Contractors to HUD are covered by the same requirements to protect privacy as HUD staff and must demonstrate that they have systems in place to protect against data disclosure.

By initialing below I certify that all the above information is correct, accurate and true to the best of my knowledge. I understand that false or misleading information may be grounds for the rejection of my application. Furthermore, I understand that the completion of the application in no way guarantees me that I will receive housing.

Initials