Final - 2528-0297_Data Destruction Certification Form4

OMB #2528-0297
Date: XX/XX/XXXX

HUD Office of Policy Development and Research (PD&R)

Data Destruction Certification Form

This certification attests to the destruction of all HUD data covered by the Data Licensing Agreement (DLA) listed below. Data destruction must encompass any and all original files, all copies made of the files, any derivatives¹ or subsets of the files and any manipulated files ever under the control of individuals allowed by the Licensee organization to have access to the data. All files in all media containing any personally identifying information from the HUD files listed below have been destroyed, and no person associated with the licensee organization, has retained such information in any form². PD&R will provide e-mail confirmation of receipt of this certification to the Principal Project Officer.

As the Principal Project Officer and on behalf of ___________________________________ (Licensee organization), I affirm that the following files received under DLA Number ____________, and, as applicable, all copies, derivatives, subsets and manipulations of those files, whether in electronic or paper form, held by ____ ______________________________ (Licensee organization) and/or any individual who had access to those files, have been destroyed.

HUD File/Document	Date Destroyed

______________________________________________________________________________

Principal Project Officer Signature Date

Return this signed form to:

Government Technical Representative

HUD-PD&R

451 7^th Street SW

Washington, DC 20410

Paperwork Reduction Act Notice. Public reporting burden for this collection of information is estimated to be 15 minutes per applicant, and includes time for reviewing the instructions, and completing and reviewing the responses. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the Reports Management Officer, Paperwork Reduction Project (2528-0297), U.S. Department of Housing and Urban Development, 451 7th Street SW, Washington, DC 20410-3600. Your completion of this information collection is voluntary. The purpose of this information collection is to further policy-relevant research on the effectiveness of HUD’s programs. This information will enable HUD to assure the destruction of d data. There are no assurances of confidentiality. HUD may not collect this information, and you are not required to complete this form, unless it displays a current, valid OMB control number.

1

A derivative file is one containing any piece of Personally Identifying Information (PII) from HUD, or any other piece of information from HUD from which an individual identity can be inferred when used in combination with information available from other sources.

2 An encrypted, password-protected data file may be transmitted to a designated representative of HUD for safekeeping, if the Licensee desires.