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<br />200809274 <br /> <br />20VOW68 <br /> <br />CHILD SUPPORT AND/OR ALIMONY VERIFICA nON <br />(Completed by Clerk of Court or Appropriate Verifying State Agency) <br /> <br /> <br />TO: <br /> <br />Name & Address of Agency <br /> <br />Unit # (if assigned) <br /> <br />Docket <br /> <br />Page # <br /> <br />RE: <br /> <br />Social Security Number <br /> <br />Applicant/Tenant Name <br /> <br />I hereby authorize release of my child support/alimony information. <br /> <br />Sib'llature of Applicant/Tenant <br /> <br />Date <br /> <br />Child's Name <br /> <br />Child's Name <br /> <br />Child's Name <br /> <br />Child's Name <br /> <br />The individual named directly above has indicatcd that he or she is receiving court-ordered support and is an applicant/tenant of a housing prob'Tam that <br />requires verification of income. The information provided will remain confidential and will be used solely for the purpose of dctermining eligibility for <br />occupancy. Your prompt response is crucial and greatly appreciated. <br /> <br />Signature of Owner's Representative <br /> <br />Return Form To: <br /> <br /> <br />This will certify that the above named person is court ordered to receive $ <br />in alimony. (A copy of the account ledger may be substituted.) <br /> <br />per <br /> <br />in child support and/or $ <br /> <br />per <br /> <br />Clerk of Court or Agency Official's Si!:,'lIature <br /> <br />Printed Name & Title <br /> <br />Date <br /> <br />Agency's Name and Address <br /> <br />Phone # <br /> <br />Fax # <br /> <br />E-mail <br /> <br />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 <br />United States as to any matter within ils jurisdiction. (Updated 11107) <br />