Laserfiche WebLink
VERIFICATION OF UNEMPLOYMENT BENEFITS <br />TO: <br />Name & Addt= of Agency <br />RE: <br />ApplicantlTenant Name <br />I hereby authotize release of my unemployment infattmetion. <br />Signature of ApplimntfTenant <br />200512600 <br />Unit # (if assigned) <br />Social Security Number <br />Date <br />The individual named directly above has indicated that he or she is receiving benefits from your agency and is an applioatnt/tenant of a housing <br />Program that requires verification of ineonnc. The information provided will remain confidential and will be used solely for the purpose of <br />dotermining eligibility for occupancy. Your prompt response is crucial and greatly appreciated. <br />Project ownedmattagenent Agent <br />Gross weekly payment to client S <br />Beginning date of payment <br />Retum Form To: <br />Ending date, if known <br />Is this client entitled to an extension of benefits? YES ❑ NO ❑ <br />If yes, for how long? <br />Signature <br />Phone 9 <br />Printed Name & Title <br />Agency's Name and Address <br />Fax # <br />Date <br />E -mail <br />VU "C Srcticn 1001 ot'Title I R of the U.S. Cede make; it a crtninal offense to make willful false statements cr misrepresentations to any Department or Agcncy of the <br />(peened Iw rtj <br />Lnacd States as to any matter within its jurisdiction. <br />