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PENSION OR WORKERS COMPENSATION VERIFICATION <br />TO: <br />Nruma & Addmn of Agency <br />RE: <br />Applit_ttt/Tenant Name <br />1 h=by authrnim release of my pension or workers cornpensadon utfortuation. <br />Signature of ApplicMUTCnant <br />200512606 <br />Utut # (if asaigncd) <br />social Security Number <br />F471 7 <br />'The individual named directly above has indicated that ho or she is receiving payment for you and is an applicandtenant of a housing program that <br />requires verification of income, The information provided will remain confidential and will be used solely for the purpose of de mnining eligibility <br />for occupancy. Your prompt response is crucial and greatly approdstw. <br />project owner/Management Agent <br />Return Form To: <br />Weekly ❑ <br />Monthly ❑ Payments to Employ= $ <br />Weeks or amount still to be paid <br />Effective Date Ending Data, if known <br />Retirement Pension Number <br />Current Gross Monthly Retirement Pension Amount <br />Total Gross Retirement Ptsnsiott Tmcome expected for the next 12 months $ <br />Additional Remarks: (please indicate any anticipated changes.) <br />Signature <br />Phon # <br />Printed Name & Title; <br />Agency's Name and Address <br />Fax # <br />Date <br />E -mail <br />NOTE: Sr ticn I Gll of Title ; A of the U.S. Code makes it a criminal Offense to make willful false statements or misrepresentations to any Departmcnt r Agcnr 12f4 <br />Cnitm States as to any matter within its jurisdiction. <br />