Distressed Housing Rehabilitation Program

Authorization Form

I hereby authorize and instruct the New Orleans WOW housing partners, which includes credit counselors, realtors, and mortgage lenders, to provide non-financial tracking data to the Community of Faith for Economic Empowerment and the Congressional Black Caucus Foundation.

If I want to revoke my consent authorizing any of the organizations to provide non-financial tracking data information to the Community of Faith for Economic Empowerment, I will notify the organization directly

Applicant Co-Applicant
   

Last Name
Last Name
   

First Name
First Name
   

Middle Initial
Middle Initial
   
Applicant Signature Applicant Signature
   

House/Street/Apt
House/Street/Apt
   

City
City
   

State
State
   

Zip
Zip
   

Day Phone
Day Phone
   

Evening Phone
Evening Phone
   

Cell Phone
Cell Phone
   

Fax
Fax
   

Email
Email
   
/ /
Date 		/ /
Date
   
Counseling agency applicant referred to:
 
How did you hear about the New Orleans LEHP program?
 

 

 

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