Authorization & Liability Waiver

Authorization & Liability Waiver

Family Housing Advisory Services, Inc.
Please Select Counselor: *
Primary Applicant Name: *

First Name Middle Name Last Name Suffix
Secondary Applicant Name (optional):

First Name Middle Name Last Name Suffix
Primary Applicant Date of Birth: *

Month Day Year
Secondary Applicant Date of Birth:

Month Day Year
Primary Applicant - Last 4 of SSN: *
Secondary Applicant - Last 4 of SSN:
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I/we, Primary Name* and Spouse name (optional) whose signature(s) appear(s) below, give permission to Family Housing Advisory Services, Inc. (hereafter "FHAS, Inc."), its employees, and/or attorneys and representatives, to consult with others and obtain from others or provide to others any and all information deemed necessary to assist me with my housing needs including, but not limited to: Information from any State or Federal agency, information regarding my income, all health, medical, and educational information.
I agree to hold FHAS, Inc., its employees, attorneys, representatives and members of its Board of Directors faultless and release them from all liability for their good faith attempt to assist me/us. I also hereby authorize any third person, agency, or organization to provide any such information requested by FHAS, Inc., regarding myself and my minor children, namely:
Minor First NameMinor Last Name Minor DOB
Minor First NameMinor Last NameMinor DOB
Minor First NameMinor Last NameMinor DOB
Minor First NameMinor Last NameMinor DOB
Minor First NameMinor Last NameMinor DOB
to FHAS, Inc., its employees, attorneys, or representatives and further, hereby fully release any such person from any liability for providing any such information. This authorization is valid for 12 months from the date below unless I have designated a shorter time in the space below or sooner revoke this authorization. A copy, electronic image or emailed version of this release shall be considered an original.

The period of authorization, if less than 12 months, is Number months from the date below.
Primary Applicant Signature: *

Clear
Today's Date: *

Month Day Year
Spouse Signature:

Clear
Today's Date:

Month Day Year
Please submit a copy of the following documents in order for us to determine eligibility.
- ID
- Social Security OR ITIN OR IRS Tax document (may be required for children if applicable)
- Notice (e.g. 3, 7, or 14-day notice) OR a ledger OR a statement from the landlord of the balance owed. You may also upload a court summons if you have one.
- Approval letter from the landlord (for deposit requests)
- Utility bill (for utility requests)
- Proof of hardship to show why you fell behind (letter from employer, paycheck stub, bank statements, medical statement)
- Money order for late fees (if applicable)
PLEASE NOTE: Submitting this application does not guarantee approval and processing can take up to 10 business days for some request. Please be advise, additional documents may be requested upon review of your application. Thank you!

Cancel of
Witness By - FHAS Employee (for office use only):

_________________________________________________

Family Housing Advisory Services, Inc.

MAIN OFFICE

2401 Lake Street

Omaha, NE 68111

402.934.7921/Fax 402.934.7928

Increasing Affordable Housing Opportunities for All

Certified by the United States Department of Housing and Urban Development (HUD) to provide Comprehensive Housing Counseling Service. TTD Access via the Nebraska Relay System. Rev. 2020
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