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EXHIBIT B-5 9 9 1 Q � � 5 �'� <br /> VERIFICATION OF SOCIAL SERVICES <br /> CLIENT: DATE: <br /> ADDRESS: <br /> TO WHOM IT MAY CONCERN: <br /> The client listed above has indicated that he or she is receiving income from your agency. Information provided will remain <br /> confidential and will be used solely for the purpose of determining eligibility for occupancy. <br /> Sincerely, <br /> Project Manager <br /> I hereby authorize the above named management agent to make inquiries regarding my income for the purpose of determining <br /> my eligibility for occupancy. <br /> Signed: <br /> Date: <br /> Detailed Budget Statement Provided <br /> Monthly payment from this Agency: <br /> AFDC GA <br /> Child Support Pass Through <br /> Other <br /> Other known income <br /> Payments over the last 6 months <br /> Remarks - Please indicate any anticipated changes in: <br /> (1) The monthly payment: <br /> (2) The family status of the Applicant: <br /> Signature of Social Worker <br /> Title <br /> Date <br /> Phone <br /> PLEASE RETURN TO: <br /> B-5-1 <br />