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TO: <br />RE: <br />Appli enant Name <br />I hereby authorize release Of my Social Security k&O"'Afic'n. <br />sipatura of Applicant/Taund <br />Social Security Number <br />FiRM <br />The individual named directly above is an applicant/tenant of a housing prograrn that requires verification of incarns. The information provided will <br />remain confidential and will be used solely fbr the purpose of deommining eligibility for occupancy. your prompt response is crucial and greatly <br />appreciated <br />Project Owner/Managoment Agent <br />Return Form To: <br />❑ The groan amount of the monthly Social Security Benefit is (do not subtract Medicare deduction.) <br />The above amount became effective —/— <br />Month / Year <br />❑ The monthly payrrmut of the Supplemental security Income payment is <br />The above amount became affective —/— <br />Month / Year <br />❑ Other inforrnation needed: <br />Complete only if you are unable to verify information requested: <br />❑ Claim Still Pending <br />❑ No record based on identifying infOnnatiO3 <br />❑ Other <br />Social Security 01FIVIAI's sitmature <br />Phone 0 <br />printcd'.Nune <br />Social Security Adni-im-dratiCn's Nam* and Addrass <br />Fax # <br />S <br />Date <br />E-Tr=l <br />nulke,4 it L Ln=; 1 Ofcnsa to Mnko wijlfitl Cijsc sLanr.cnt9 or nusrrprescnwtions to Any Da-pri.,nent t,r At sr- [!'c <br />A,;:�,inv matter within its; urisdtction. <br />