Application for Data License

OMB #2528-0297

Date XX-XX-XXXX

Affidavit of Nondisclosure

___________________________________ ______________________________

(Job Title) (Date Assigned to Work with HUD PII Data)

____________________________________

(Organization, State or Local Agency Name)

____________________________________

(Organization or Agency Address) (HUD File Containing PII*)

I, __________________________________ , do solemnly swear (or affirm) that when given access to the subject HUD database or file, I will not –

(i) use or reveal any individually identifiable information furnished, acquired, retrieved or assembled by me or others for any purpose other than statistical, research, or evaluation purposes specified in the approved data license application;

(ii) make any disclosure or publication whereby a sample unit or survey respondent could be identified or the data furnished by or related to any particular person under these sections could be identified; or

(iii) permit anyone other than the individuals authorized by the HUD to examine the individual reports.

[Under the Privacy Act, unlawful disclosure of PII data is a misdemeanor and subject to a fine of up to $5,000.]

___________________________________

(Signature)

City/County of _________________ Commonwealth/State of ________________ .

Sworn to and subscribed before me this _______________ day of

_______________, 20________ . Witness my hand and official Seal.

____________________________________

(Notary Public/Seal) My commission expires__________________ .

* Request all subsequent follow-up data that may be needed. This form cannot be amended by HUD, so access to datasets not listed will require submitting additional notarized Affidavits.

Paperwork Reduction Act Notice. Public reporting burden for this collection of information is estimated to be 1 hour per applicant, and includes time for reviewing the instructions, and completing and reviewing the responses. Your completion of this information collection is voluntary. HUD may not collect this information, and you are not required to complete this form, unless it displays a current, valid OMB control number.