The Poinsett County Housing Authority is a federally-funded agency assisting qualified families with rent subsidies. The above named person is an applicant for, or a participant in, a federally-assisted housing program operated by the Paragould Housing Authority. All income and expenses reported to the authority must be verified in writing to determine his/her eligibility and rent payment. Please complete the lower part of this form and return by mail or fax as soon as possible.

I do hereby authorize the release of all information requested below to the Poinsett County Housing Authority for the purpose of determining my eligibility for housing assistance.

For Office of Child Support Enforcement Use Only

Warning! Title 18, Section 1001 of the United States Code, states that a person who knowingly and willingly makes false or fraudulent statements to any department or agency of the United States is guilty of a felony.

If you are disabled or have difficulty understanding English, please request our assistance and we will ensure that you are provided with meaningful access based on your individual needs.

Si usted es desactivar o tiene dificultad para entender Ingles, por favor solicite neustra ayuda y nos aseguramos de que se le proporciona un acceso significativo basado en sus necesidades individuales.

Haddii aad tahay wuxuu curyaamin ama ay ku adag tahay fahamka Ingiriisi, fadlan codsato gargaarka oo aan loo hubiyo in aad waxaa la siiya helaan macno leh oo ku salaysan baahiyahaaga shaqsi.

PLEASE RETURN TO: Poinsett County Housing Authority, 1104 Elm Street, Marked Tree, AR 72365 OR
FAX TO: (870) 358-4537