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CHILD supPORT AND /OR ALIMONY VERMCATYON <br />(Completed by Clerk of Court or Appropriate Verifying state Agency) <br />TO: <br />Name Bc Addresa of Agency <br />RR- <br />Applicanf/'I'enewt Norm <br />I hereby euthorin release ormy child suppod/aliumY won- <br />Si of Applicant/ Tenant <br />Child's Name <br />Child's Name <br />200512606 <br />Unit # (if assigned) <br />Docket <br />Page # <br />Social Security Number <br />Data <br />Child's Name <br />Child's Name <br />The individual named directly above has indicated that he or she is receiving court-ordered support and is an applicant/tenwA of a housing program that <br />requires verification of income. The information provided will remain confidential sad will be used solely for the purpose of determining eligibility for <br />occupancy. Your prompt response is crucial and greatly appreciate& <br />project pwnedMsmagerrsent Agent <br />Return Form To: <br />This will certify that the above named person is court orderod to receive S per in child support and/or S per <br />in alimony. (A copy of the account ledger may be substituted.) <br />Clerk of Court or Agency Official's Signature <br />Phone # <br />Printed Narnc & Title catc <br />Agency's Name and Address <br />Fax # E -trail <br />sect;�)n 1(iol iie t.'.e tk of th [: S, code rnuices it � criminal nttensa to make xtlt ill false slstemdnLs:Sr misrapresentatiana to uny G puP mct7tcr pia S 12,(14, <br />to any m a-'e'r %&: -ain tt8 <br />