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JJANK VLi'KLI ICA ION <br />TO: <br />Name & Adt�ress of Financial Institution <br />RE: <br />Applicant/Tenant Nano <br />Applicsint/Tenant Name <br />I hereby authorise release of my asset information. <br />Signature of Applicant/Tenant <br />Signature of Applica nt/Tc rant <br />200512606 <br />Unit # (if assigned) <br />Social Security Number <br />Social Security Number <br />I <br />FITM <br />The individual named direedy above is an applicantltermt of a housing program. that requites vcrificatian of income The in%nmation provided will remain <br />confidential and will be used solely for the purpose of determining eligibility for occupancy Your prompt response is crucial and greatly appreciated. <br />Project Oamer/Mnnagcment Agent <br />Return Form To: <br />SAVINGS ACCOUNT: <br />Acct #: — <br />Currant Balance $ <br />Current % Rata _ <br />CHECKING ACCOUNT: <br />Acct #: <br />Average Balance for the Past Six Months: $ <br />Current Balance: S <br />Rate of Interest: % <br />SAVINGS ACCOUNT`. <br />Acct #. <br />Current Balance $ <br />Current % RAM <br />CHECKING ACCOUNT: <br />Acct #: <br />Average Balance for the Past Six Months: S. <br />Cttmr►t Balances S <br />Rate of lntercar % <br />Please list other asset accounts below (Certificates of Deposit, MoncY Market Funds, Trust, IRA's, etc.) <br />Account Type of Bate of <br />Number Balance Account Interest <br />S — — % <br />*NOTE: CASH VALUE IS THE CURRENT VALUE MINAS ANY PENALTIES FOIL EARLY WITHDRAWAL. <br />Signature printed Narw & Title <br />Phone 4 <br />Sank Name and Address <br />Fax # <br />Cash Value* <br />S <br />S <br />S <br />Date <br />E -mail <br />TOTE: Section 1001 of Tii C 18 of the US, Code makes it a criminal offense to make willful False statements Of misrepresentations to any Department or A encyd f t 1 U04) t <br />States as to any matter'- :i its jurisdicrion. <br />