Privacy Act Statement. The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937, as amended (42 U.S.C. 1437 et. seq.); the Housing and Urban-Rural Recovery Act of 1983 (P.L. 98-181); the Housing and Community Development Technical Amendments of 1984 (P.L. 98-479); and by the Housing and Community Development Act of 1987 (42 U.S.C. 3543). The information is being collected by HUD to determine an applicant’s eligibility, the recommended unit size, and the amount the tenant(s) must pay toward rent and utilities. HUD uses this information to assist in managing certain HUD properties, to protect the Government’s financial interest, and to verify the accuracy of the information furnished. HUD, the owner or management agent (O/A), or a public housing agency (PHA) may conduct a computer match to verify the information you provide. This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatory investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. You must provide all of the information requested. Failure to provide any information may result in a delay or rejection of your eligibility approval.
Privacy Act Statement. The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). All information collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR 210. This information will be used by the Treasury Department to transmit payment data, by electronic means to vendor's financial institution. Failure to provide the requested information may delay or prevent the receipt of payments through the Automated Clearing House Payment System. FEDERAL PROGRAM AGENCY AGENCY IDENTIFIER: AGENCY LOCATION CODE (ALC): ACH FORMAT: CCD+ CTX ADDRESS: CONTACT PERSON NAME: TELEPHONE NUMBER: ( ) ADDITIONAL INFORMATION: NAME SSN NO. OR TAXPAYER ID NO. ADDRESS CONTACT PERSON NAME: TELEPHONE NUMBER: ( ) NAME: ADDRESS: ACH COORDINATOR NAME: TELEPHONE NUMBER: ( ) NINE-DIGIT ROUTING TRANSIT NUMBER: DEPOSITOR ACCOUNT TITLE: DEPOSITOR ACCOUNT NUMBER: LOCKBOX NUMBER: TYPE OF ACCOUNT: CHECKING SAVINGS LOCKBOX SIGNATURE AND TITLE OF AUTHORIZED OFFICIAL: (Could be the same as ACH Coordinator) TELEPHONE NUMBER: ( ) AUTHORIZED FOR LOCAL REPRODUCTION SF 3881 (Rev. 2/2003 ) Prescribed by Department of Treasury 31 U S C 3322; 31 CFR 210 Make three copies of form after completing. Copy 1 is the Agency Copy; copy 2 is the Payee/Company Copy; and copy 3 is the Financial Institution Copy.
Privacy Act Statement. Collection and use is covered by Privacy Act System of Records INTERIOR/DOI–05 Interior Volunteer Services File System (which may be viewed at xxxxx://xxx.xxx.xxx/privacy/doi-notices) and OPM/GOVT–1 General Personnel Records (which may be viewed at xxxxx://xxx.xxx.xxx/information-management/privacy-policy/#url=SORNs) and is consistent with the provisions of 5 USC 552a (Privacy Act of 1974), which authorizes acceptance of the information requested on this form. The information is used to identify persons interested in participating in a government volunteer program, managing the volunteer program, including tort claims and injury compensation. Records or information contained in this system may be disclosed outside the agencies participating in this program as a routine use pursuant to 5 U.S.C. 552a(b)
Privacy Act Statement. Authority ─ This information is being collected under the authority of 5 U.S.C. § 4115, a provision of The Government Employees Training Act.
Privacy Act Statement. The NIH maintains application and grant records as part of a system of records as defined by the Privacy Act: NIH 09-25-0225 xxxxx://xxx.xxx.xxx/privacy-act-and-era.htm.
Privacy Act Statement. Section 6109 of the Internal Revenue Code requires you (Issuer) to provide us with your correct Taxpayer Identification Number (TIN).
Privacy Act Statement. The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). All information collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR 210. This information will be used by the Treasury Department to transmit payment data, by electronic means to vendor's financial institution. Failure to provide the requested information may delay or prevent the receipt of payments through the Automated Clearing House Payment System. FEDERAL PROGRAM AGENCY AGENCY IDENTIFIER: AGENCY LOCATION CODE (ALC): ACH FORMAT: CCD+ CTX ADDRESS: CONTACT PERSON NAME: TELEPHONE NUMBER: ( ) ADDITIONAL INFORMATION: NAME SSN NO. OR TAXPAYER ID NO. ADDRESS CONTACT PERSON NAME: TELEPHONE NUMBER: ( ) NAME:
Privacy Act Statement. Section 1173 of the Social Security Act authorizes the adoption of a standard unique health identifier for all health care providers who conduct electronically any standard transaction adopted under 45 CFR 162. The purpose of collecting this information is to assign a standard unique health identifier, the NPI, to each health care provider for use on standard transactions. The NPI will simplify the administrative processing of certain health information. Further, it will improve the efficiency and effectiveness of standard transactions in the Medicare and Medicaid programs and other Federal health programs and private health programs. The information collected is entered into a system of records called the National Plan and Provider Enumeration System (NPPES), HHS/CMS/OIS No. 09-70-0008. In accordance with the NPPES Data Dissemination Notice (CMS-6060), published May 30, 2007, certain information that you furnish will be publicly disclosed. The NPPES Data Dissemination Notice can be found at xxxxx://xxx.xxx.xxx/Regulations-and- Guidance/Administrative-Simplification/NationalProvIdentStand/Downloads/DataDisseminationNPI.pdf Employee understands and acknowledges the following: • Employee is employed by the participant. Employee is not employed by the State of West Virginia or PPL • Employment is “at-will”. No guarantee or promise of continued employment is intended or implied by this agreement • In accordance with the Fair Labor Standards Act, employee is considered a domestic employee providing homecare companionship services to a household employer and is therefore not entitled to overtime pay for hours worked in excess of 40 hours per week for a single employer • In West Virginia household employers are not required to obtain worker’s compensation insurance coverage. Employers may not use funds from the approved budget for worker’s compensation coverage • Employee is responsible for informing the employer of any non-workplace injury that would interfere with the performance of their duties. The employee is responsible for reporting workplace injuries to the employer within 24 hours • IMPORTANT: Any false claims, statements, documents or concealment of material facts by employer or employee may be considered Medicaid fraud and will be reported for review and potential prosecution under applicable Federal and State laws
Privacy Act Statement. The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). All information collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR 210. This information will be used by the Treasury Department to transmit payment data, by electronic means to vendor's financial institution. Failure to provide the requested information may delay or prevent the receipt of payments through the Automated Clearing House Payment System.
Privacy Act Statement. The Department of Housing and Urban Development (HUD) is authorized to collect the information required on this form by Section 8 of the U.S. Housing Act of 1937 (42 U.S.C. 1437f). Collection of family members’ names and unit address, and owner’s name and payment address in mandatory. The information is used to provide Section 8 tenant-based assistance under the Housing Choice Voucher program in the form of housing assistance payments. The information also specifies what utilities and appliances are to be supplied by the owner, and what utilities and appliances are to be supplied by the tenant. HUD may disclose this information to Federal, State, and Local agencies when relevant to civil, criminal, or regulatory investigations and prosecutions. It will not be otherwise disclosed or released outside of HUD, except as permitted or required by law.
