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200809274 LIFE INSURANCE VERIFICA nON 2 o\l(fM1!Ji 8 TO: Name & Address Phone Number Fax Number RE; Applicant/Tenant Name Social Security Number Unit # (if assigned) I hereby authorize release of my life insurance information. Signature of ApplicanUTenant Date The individual(s) named directly above is an applicanUtenant 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 appreciated, Signature of Owner's Representative Return Form To: Policy Account # Dividend Paid and/or Interest Rate (this includes reinvested interest/dividends) Cash Surrender Value C'N! A" ifna interest Or dividend paid) $ $ % $ $ % $ $ % Does the applicanUtenant have access to the lump sum amount? DYes DNo Is the applicant/tenant receiving periodic payments DYes D No If yes, what amount $ Frequency Additional Remarks: (please indicate any anticipated changes.) SIgnature Pnnted Name & TItle Date Name and Address Phonc # Fax # E-maIl NOTE: Section 100 I of Title IS of the U.S. Code makes it a criminal offense to make willful false statements ar misrepresentations to any Department or Agency of the United States as to any mailer within its jurisdiction. (Updated 11107)