Authorization, Disclosure, and Privacy Statement Form for Mt. Airy CDC Housing Counseling
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Email *
Client Name (if applying jointly, other client must also fill out and sign another copy of this Authorization form)
I understand that Mt. Airy CDC provides housing counseling services, rehabilitates and develops for-sale and/or rental housing, rehabilitates and develops commercial properties and that Mt. Airy CDC provides marketing services for small business, promotional services for small businesses, sponsors special events related to small businesses, and provides technical assistance to small business owners. I understand that Mt. Airy CDC receives Congressional funds through the U.S Department of Housing and Urban Development (HUD), the Philadelphia Office of Housing and Community Development (OHCD), and the National Foreclosure Mitigation Counseling (NFMC) program; and as such, is required to share some of the personal information with HUD, OHCD, and NFMC program administrators to their agents for purposes of program monitoring, compliance, and evaluation. I give permission for Mt. Airy CDC to collect such nonpublic personal and financial data as required to render counseling services on my behalf, including but not limited to, credit reports. I give permission for said personal data to be shared with third parties as determined that it would be helpful to me, would aid in counseling me, is a requirement of grant awards which make services possible, or is required by law. I give permission for Mt. Airy CDC to act on my behalf as advocate or ombudsman concerning all third party negotiations necessary in providing counseling services.I give permission for said third parties to follow up with me regarding shared data and counseling services provided. I understand that I may “opt-out” of disclosure of my nonpublic personal information to third parties.  I understand that if I choose to “opt-out”, Mt. Airy CDC  will not be able to answer questions from third parties. I understand that if I have not opted-out, Mt. Airy CDC may disclose some or all of the information collected to third parties where we have determined that it would be helpful to me, would aid in counseling me, or is a requirement of grant awards which make services possible, or is required by law. I understand that I may change my decision with regard to “opting-out” by calling Mt. Airy CDC at 215-844-6021, option 1. *
I understand that Mt. Airy CDC provides counseling, information and education on loan products and housing programs to interested consumers at no charge.  These services are provided to assist me with housing – related needs.  In the course of providing assistance, it may be determined that I am eligible for certain programs, products, and services.   I understand that a list of these services is provided on the next page and these services have been explained to me. I understand that I am not obligated to use or receive any programs, products and services offered, regardless of any recommendations made by counselors, or other agency members, or personnel. I understand that I am being provided counseling, informational and educational services only, and that these services are not meant to be legal representation, brokerage services or any other professional relationship.  I understand that a counselor may answer questions and provide information, but not give legal advice.  If I want legal advice, I will be referred for appropriate assistance.I understand that Mt. Airy CDC shall bear no responsibility for the outcome of circumstances for which a client may be subject to as a result of problems disclosed to Mt. Airy CDC. I understand that this Authorization is a three page form, and that this form is not valid unless all pages are together. *
Counseling & Services Checklist (you must check all boxes) *
Required
Client Checklist (please select 1) *
Client Signature - typing in my name below serves as my electronic signature.  By signing, I certify that I have read and understand the above statements.  I authorize my employers, lenders, creditors, servicers, and others to share personal and financial information with my Counselor and Mt. Airy CDC. I authorize my Counselor and Mt. Airy CDC to collect information about my accounts and to share this information with others, including funders, as needed to provide counseling services, to seek assistance from programs, or for related products and services. I authorize funders to contact me to evaluate programs that I participate in. *
Date *
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A copy of your responses will be emailed to the address you provided.
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