Social Security Deduction Questionnaire - EIV

Date:
Property Name: / Telephone:
Address: / Fax:
City, State, Zip: / TTD/TTY:

TO:

Name
Address:
Unit Number
City, State, Zip

According to HUD requirements, the owner/agent is required to use HUD’s Enterprise Income Verification System to verify income. EIV provides information verifying certain Social Security income and deductions.

Your EIV Social Security Income Verification reflects an unexplained difference between your gross benefit and your net payment. This difference may affect your assistance payment. If so, we will assist you in obtaining a current Award Letter from SSA so that you receive all the assistance you deserve.

According to EIV, your current gross SSA award is $

Your Medicare Deduction is $

This should result in a net payment of $

However, your net payment is $

Please provide information about the additional deductions causing the difference between your gross SSA benefit and your net SSA benefit.

Medicare Part D $ ______(requires additional verification)

Repayment for a prior overpayment $ ______(requires additional verification)

Repayment for unpaid child support $ ______(not be used for rent calculation)

Repayment for unpaid taxes $ ______(not be used for rent calculation)

Repayment for unpaid student loans $ ______(not be used for rent calculation)

Repayment for unpaid FHA Mortgage $ ______(not be used for rent calculation)


Other______$ ______

The only deductions that I am aware of are already indicated on the income report.

PENALTIES FOR MISUSING THIS VERIFICATION FORM
Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government, HUD, the PHA and any owner (or any employee of HUD, the PHA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the PHA or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7) and (8). Violation of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).

By my signature I certify that the information I have provided above is true and complete to the best of my knowledge and belief. I understand that if I furnish false or incomplete information I can be fined up to $10,000 or imprisoned up to five years, or lose the subsidy HUD pays and/or have my rent increased. I understand that any assistance paid in error must be returned to HUD.

______

Signature Date

Page 1 of 2 Revised 11/2012