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<br />200809274 2~~68 <br />CHILD SUPPORT AND/OR ALIMONY VERIFICATION <br />(Completed by Payer) <br /> <br /> <br />TO: <br /> <br />Name & Address of Payer <br /> <br />Unit # (if assigned) <br /> <br />RE: <br /> <br />Social Security Number <br /> <br />Applicant/Tenant Name <br /> <br />I hereby authorize release of my child support/alimony intormation. <br /> <br />Signature of Applicant/Tenant <br /> <br />Date <br /> <br />The individual named directly above has indicated that he or she is receiving support and is an applicant/tenant of a housing program that requires <br />veril1cation of income. The intormation provided will remain conlidential and will be used solely for the purpose of determining eligibility for occupancy. <br />Your prompt response is crucial and greatly appreciated. <br /> <br />Sib'1lature of Owner's Representative <br /> <br />Return Form To: <br /> <br /> <br />This will certify that I pay $ <br /> <br />per <br /> <br />in child support to (Name); <br /> <br />for the support ofChild(ren) Name(s): <br /> <br />This will certify that I pay $ <br /> <br />per <br /> <br />in alimony to (Name): <br /> <br />Signature <br /> <br />Printed Name <br /> <br />Date <br /> <br />NOTE: Section 1001 of Tille 18 uflhe U.S. Code makes il 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 its jurisdiction. (Updated 11/07) <br />