Page 64

DEO LIHEAP Policies and Procedures Manual Page 64

EXHIBIT 3 Notice of Collection of Social Security Numbers The following disclosure is being made pursuant to section 119.071(5), Florida Statutes. Social security numbers of applicants and household members are requested because this information is crucial for the performance of the duties and responsibilities prescribed by law under the Low-Income Home Energy Assistance Program. This information is not required by state or federal law; however, social security numbers are necessary to determine eligibility for program services and specifically for the following purposes: 1. To verify an applicant’s identity 2. To verify household size 3. To verify household income

A social security number collected pursuant to this notice can only be used by the Florida Department of Economic Opportunity and (Sub-Recipient) for the purposes specified above. Nondisclosure except under limited circumstances. Social security numbers will not be disclosed to others unless required or authorized by Florida law. Section 119.071(5), Florida Statutes, allows disclosure of a person’s social security number under the following specific, limited circumstances: • If disclosure is expressly required by Federal or Florida law or is necessary for the subrecipient or governmental entity to perform its duties and responsibilities • If the individual expressly consents to disclosure in writing • If disclosure is made to prevent and combat terrorism pursuant to the U.S. Patriot Act of 2001 or Presidential Executive Order 13224 (blocking property and prohibiting business transactions with persons who commit, threaten to commit, or support terrorism) • (For a subrecipient employee and dependents), if disclosure is necessary to administer the person’s health benefits or pension plan funds, or • If disclosure is for the purpose of the administration of the Uniform Commercial Code by the office of the Secretary of State • If disclosure is requested by a commercial entity for permissible uses under the federal Driver’s Privacy Protection Act of 1994, the federal Fair Credit Reporting Act, or the federal Financial Services Modernization Act of 1999 (for example, to verify the accuracy of personal information provided by the individual to the commercial entity; use by an insurer in connection with claims investigation or anti-fraud activities; for use in connection with a credit transaction).

Acknowledgment of Receipt of Notice I confirm that I have been provided a copy of this Notice regarding the collection of my social security number and the social security numbers of all household occupants as part of the application process for the Florida Low Income Home Energy Assistance Program.

Signature of Applicant Signature of Subrecipient Staff