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200512606 <br />CHILD SUPPORT AND /OR ALIMONY VERIFICATION <br />(Completed by Payer) <br />To: <br />Name & Address of Payer Unit * (if assigned) <br />RE: <br />Apphcwd/Tenmt Name Social Security Number <br />Y hereby Authorize teleaso of my child supportfaUrnony information. <br />Signature of A.pplicant/Tenant Date <br />The individual named directly above has indicated dud he or she is receiving support and is an applicant/tenant of a housing pro gram that requires <br />verification of incama. The inforrntioa provided will remain confidential and will be used solely for the purpose of determinin eli.glbility. for occupancy. <br />your pran7pt response is crucial and greatly appreciata& <br />projeot OwnerNManagemaat Agent <br />Return Form To: <br />This will certify that T pay $ Per <br />for the support of llild(rm) Name(s): <br />This will certify that 1 pay $ per <br />Signature <br />in child support to (Name): <br />in alimony to (Name): <br />Printed Name <br />Date <br />NOTE: Section (':ill of "lint 1'i cfthe � :. . Code nwkcs it u criresnal otlanso to rn++kc Hii1:u1 fidse statcr, nts cr misrcpresentalions W .ny Depar tnent dr .�ycrcy :I, the <br />i 1, F'iated 1164, <br />�; :cd :i!4tes as to any rratter within its jursdicttun, <br />