Form of Authority

Release of Information to a nominated person or an external agency.

I/We

Name/s of Customer

Customers Address

give consent for Cunninghame Housing Association to share and obtain relevant information with the following:

Person or External Agency:

Name

Address

Telephone Number

Email Address

I/We agree that the following personal details can be released: (Please tick as appropriate)

My name and address
My income (e.g. pension, benefit, wages)
My rent, arrears, service charges, sub-charges and housing benefit
Details of my housing options and applications
Details of my tenancy agreement, including changes to my tenancy and details of my household members
Details of actions taken by CHA that may affect me (e.g. eviction notices, communal repair notices)
Details of complaints that may have been raised by myself or by others against me
I would like all written correspondence sent to the above nominated person or agency instead of my home address

following Name Signature

Signature

Date