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ko <br />RE: <br />Applicantfrenant Name <br />1 hereby authorize releeaa of my Social stxvicea infom"tim <br />Sigtratare of App►icartt/1'etrtmt <br />Social Security Number <br />Date <br />The client named directly above has indicated that he or She is Mdving itu:orrte &= your agency. The information provided will remain confidential and <br />will be used solely for the purpose of det�enmitring eligibility for occupancy. Your prompt regionse is crucial and greatly apprccisted. <br />Project owne;dManagememt Agent <br />Return Form To: <br />Monthly paymant from this Agency* <br />TANF/AFM <br />Child Support Pass Through <br />Other <br />Other known income <br />Remarks - Please indicate =y anticipated changes in: <br />(1) The monthly payment: <br />(2) The family status of the Applicant: <br />Sat W Wod=,s Signature <br />Phone # <br />General Assistance <br />Social Worker's Printed Name Date <br />Agency Name and Address <br />Fax 4 E -mail <br />i iOTE: Section I CA) i of Tide 18 of the U.S. Code makes it a criminal offense to make wi4ful falsc statements oT misrepresentations to ary D partmcrt �r Agency of he <br />Un;tW States as to any matTer within itsjurisdictio' r,l.pdated 12:31) <br />