Phone: Fax:
Phone: Fax: / Email:
We are required to verify the income of applicants/residents living in affordable housing. To comply with this requirement, we ask your cooperation in supplying the information requested below regarding the referenced applicant/resident. Information provided will remain confidential. Please complete and return this form as soon as possible. If sent by mail, a stamped, self-addressed return envelope is enclosed. If sent by fax/e-mail, please use the fax number/e-mail address listed above. If you have any questions please call the telephone number listed above.
Owner/Owner’s Agent Signature: / Date:
RE: Applicant/Resident: / Social Security Number:
Applicant/Resident: You do not have to sign this form if either the requesting organization (property name, address, and phone/fax) or the organization (company name, address, and phone/fax) supplying the information is left blank.
RELEASE: I hereby authorize the release of the requested information. Information obtained under this consent is limited to information that is no older than twelve (12) months. There are circumstances which would require the Owner to verify information that is up to five (5) years old which would be authorized by me on a separate consent attached to a copy of this consent.
Applicant/Resident Signature: / Date:
INFORMATION REQUESTED: If the item does not apply, please indicate by placing “N/A” where appropriate.
Date Assistance began: (m/d/y)
or Date Assistance “will begin”: (m/d/y) / Total # of Household Members:
# Adults:_____ # of Children: _____
Temporary Assistance for Needy Families (TANF) monthly benefit: / $
General Assistance monthly benefit: / $
Other “Assistance” per month:
Food Stamps: $______Medicaid: $______Child Care: $______Child Support: $______
Child Support Disregard: $ Other: $
Other known Income (Source): / $
Are there any “pending” or “future” changes expected for any of the above items? ____ Yes ____ No If “yes”,
list item(s) that will change:______Date of change (m/d/y)______
Amount of benefit(s) for each change: $ $ $
Termination of Benefits:(If applicable) Date of termination (m/d/y): ______
Has applicant re-applied for benefits: ____ Yes ____ No If yes, when will they go into effect (m/d/y):______
Amount of monthly benefit(s): $
Warning: Section 1001 of Title 18, United State code provides: “Whoever, in any matter within any jurisdiction of any department or agency of the United States knowingly or willfully falsifies, conceals or covers up… a material fact, or makes any false, fictitious or fraudulent statements or representation, or makes any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than 5 years or both.”
Printed name of person supplying the information: / Printed title of person supplying the information:
Signature:
Date: / Telephone:
Public Assistance Verification (05/11)Page 1 of 1TC-5