200809274 - Laserfiche WebLink

Browse

200809274 ANNUITY VERIFICATION 2\l01D 6 8 TO: Name & Address of Financial Institution Phone Number Fax Number RE: Social Security Number ApplicantJTenant Name Unit # (if assigned) I hereby authorize release of my annuity information, Signature of ApplicantJTcnant Date The individual named directly above is an applicant/tenant of a housing program that requires verification of income. The information provided will remain confidential and will be used solely for the purpose of determining eligibility for occupancy. Your prompt response is crucial and greatly apprcciated. Sil,'llature of Owner's Representative Return Form To: I Type of Annuity held: D Fixed D Variable DHybrid D Immediate D Life D Other Current/Market Value: $ Cash Value"': $ DNo DoeS the applicant/tenant have access to the lump sum amount in the annuity? DYes Is the applicant/tenant receiving periodic payments? 0 Yes D No If yes, what amount: Is the annuity earning interest and/or dividends? (this includes reinvested interest/dividends) DYes D No If yes, what amount: $ $ % Frequency: Frequency: "'Cash Value is the current value less the cost to turn the asset into cash. Additional Remarks: (please indicate any anticipated changes.) Signature Printed Name & Title Date Financial Institution Name and Address Phone # Fax # E-mail NOTE: Section 1001 of Title 18 of the U.s. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the United States as to any matter within its jurisdiction. (Updated 11/07)