And Urban Development

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Project Planning and Management Life Cycle

[Insert System or Project Name]

[Insert Name of Program Office]

System of Records Notice Form

Version Number: > Version Date:

U.S. Department of Housing and Urban Development | System of Records Form Version 5, March 2, 2017 1 BACKGROUND INFORMATION

It is HUD’s policy to publish a system of records notice (SORN) in the Federal Register for any agency-maintained information technology (IT) or paper file system that contains personally identifiable information and retrieves the information by a personal identifier.

It is also HUD’s policy to annually certify the accuracy and completeness of existing SORN publications, and publish later revisions in the Federal Register.

The Department’s Office of Administration reviews and approves all new and revised SORNs. Once approved, new or revised SORNs will be published in the Federal Register and placed on HUD’s intranet.

VERSION HISTORY [Provide information on how the development and distribution of the system of records notice edits will be controlled and tracked. Use the table below to provide the version number, the author implementing the version, the date of the version, the name of the person approving the version, the date that version was approved, and a brief description of the reason for creating the revised version.]

Version Implemented Revision Approved Approval Description of Number By Date By Date Change 1.0 2.0 3.0

Check box next to the SORN requirement being conducted under this review.

This is a new SORN.

This is a revision for an existing SORN. This is an annual certification for an existing SORN. This is a correction for an existing publication.

U.S. Department of Housing and Urban Development | System of Records Form Version 5, March 2, 2017 2 Version date:

4210.67

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT

[Docket No. FR-XXXX-N-XX]

Privacy Act of 1974, Department of Housing and Urban Development, [Component Name] [SORN Number], [Title of System] System of Records

AGENCY: Department of Housing and Urban Development, Privacy Office

ACTION: Notice of a [New/Modified] System of Records.

SUMMARY: [Insert a plain-language description of the system].

DATES: EFFECTIVE DATE: This notice action shall be effective immediately, which will become effective [30 DAYS after date of publication in the Federal Register].

[COMMENTS DUE DATE]: [Insert date 30 days after publication in the Federal Register].

ADDRESSES: You may submit comments, identified by docket number HUD-2017- [XXXX] by one of the following methods:

Federal e-Rulemaking Portal: http://www.regulation.gov. Follow the instructions provided on that site to submit comments electronically. Fax: 202-619-8365 Email: [email protected]. Mail: Attention: Privacy Office; [PPOC Name]; The Executive Secretariat; 451 Seventh Street, SW, Room 10139; Washington, DC 20410. Instructions: All submission received must include the agency name and docket number for this rulemaking. All comments received will posted without change to http://www.regulation.gov. including any personal information provided. Docket: For access to the docket to read background documents or comments received go to http://www.regulations.gov.

U.S. Department of Housing and Urban Development | System of Records Form Version 5, March 2, 2017 3 FOR FURTHER INFORMATION CONTACT: The Privacy Office; 451 Seventh Street, SW, Room 10139; Washington, DC 20410; telephone number 202-708-3054 (this is not a toll- free number). Individuals who are hearing- or speech-impaired may access this telephone number via TTY by calling the Federal Relay Service at 800-877-8339 (this is a toll-free number).

SUPPLEMENTARY INFORMATION: [Insert background information about the proposal, including a description of any changes being made to the system and the purpose(s) of the changes].

SYSTEM NAME AND NUMBER: [A number for the system that is unambiguous and clearly identifies the purpose of character of the system and the number of the system].

SECURITY CLASSIFICATION: [An indication of whether any information in the system is classified].

SYSTEM LOCATION: [The address of the agency and/or component responsible for the system, as well as the address of any third-party service provider]. (e.g., Records are maintained at the Department of Housing and Urban Development Headquarters, 451 Seventh Street, SW, Room 4156, Washington, DC 20410.)

Note: Also, include the HUD Field and Regional Offices, contractors, and records storage facility addresses, when applicable. The complete address is required for each organization requiring access to the information maintained, collected, used, or disseminated by your system.

SYSTEM MANAGER(S): [The title, business address, and contact information of the agency official responsible for the system].

AUTHORITY FOR MAINTENANCE OF THE SYSTEM: [The specific authority that authorizes the maintenance of the records in the system].

Purpose(S) Of The System: [A description of the agency’s purpose(s) for maintaining the system].

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM: [The categories of individuals on whom records are maintained in the system].

CATEGORIES OF RECORDS IN THE SYSTEM: [Insert the categories of records maintained by the system. This information should be listed in bullet form and categorized. Examples of these format/requirements are provided below. Depending on your system, this list will be more or less detailed. Clarify whether the system’s information is collected on individual program participants and/or sole proprietors. Proper distinction of this information allows the proper establishment of Privacy Act controls].

U.S. Department of Housing and Urban Development | System of Records Form Version 5, March 2, 2017 4 RECORD SOURCE CATEGORIES: [The categories of sources of records in the system].

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES OF USERS AND PURPOSES OF SUCH USES: [Each routine use of the records in the system, including the categories of users and the purpose of such use].

POLICIES AND PRACTICES FOR STORAGE OF RECORDS: [The policies and practices of the agency regarding retention and disposal of records].

ADMINISTRATIVE, TECHNICAL, AND PHYSICAL SAFEGUARDS: [A description of the administrative, technical, and physical safeguards to which the system is subject].

RECORD ACCESS PROCEDURES: [The agency procedures whereby an individual can be notified, at his or her request, how he or she can gain access to any record pertaining to him or her in the system].

CONTESTING RECORD PROCEDURES: [The agency procedures whereby an individual can be notified, at his or her request, how he or she can contest the content of any record pertaining to him or her in the system].

NOTIFICATION PROCEDURES: [The agency procedures whereby an individual can be notified at his or her request if the system contains a record pertaining to him or her].

EXEMPTIONS PROMULGATED FOR THE SYSTEM: [Any Privacy Act exemptions promulgated for the system].

HISTORY: [Citation(s) to the last full Federal Register notice that includes the elements required to be in a SORN, and any later notices of revisions].

______Helen Goff Foster Chief Administrative Officer and Executive Secretary Senior Agency Official for Privacy

U.S. Department of Housing and Urban Development | System of Records Form Version 5, March 2, 2017 5