MSHDA 72 - Michigan



Head of Household Information:Name of MSHDA Applicant/Participant: FORMTEXT ?????Last 4 SSN: FORMTEXT ????Date of Birth: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip Code: FORMTEXT ?????The above Head of Household is a current or prospective resident of the below-referenced Low Income Housing Tax Credit (LIHTC) or Project-Based (PB) development and has indicated that they are an applicant/participant in the Housing Choice Voucher (HCV) Program. The Head of Household is authorizing release of the Tenant Data Summary (HUD-50058) to:Owner Information:Development Name: FORMTEXT ????? Development Representative: FORMTEXT ?????Where to mail HUD 50058:Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip Code: FORMTEXT ?????Phone Number: FORMTEXT ?????Fax Number: FORMTEXT ?????E-Mail Address: FORMTEXT ?????Requested Certification Type: FORMCHECKBOX New Admission FORMCHECKBOX Annual Re-Exam FORMCHECKBOX Interim Re-Exam FORMCHECKBOX MoveEffective date of Requested Certification: FORMTEXT ?????AUTHORIZATION TO RELEASE INFORMATIONI, the undersigned, on behalf of myself and the members of my household, authorize the Michigan State Housing Development Authority (MSHDA) to release the Tenant Data Summary (HUD-50058) to the above Development. Printed Name: FORMTEXT ?????Date:Head of Household Signature: X ................
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