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<br />200809274 <br /> <br />MUTUAL FUNDS/STOCK/BONDS VERIFICATION <br /> <br />~am8968 <br /> <br /> <br />TO: <br /> <br />Name & Address ofFinancial Institution <br /> <br />Phone Number <br /> <br />Fax Number <br /> <br />RE: <br /> <br />Applicant/Tenant Name <br /> <br />Social Security Number <br /> <br />Unit # (if assigned) <br /> <br />I hereby authorize release of my asset information, <br /> <br />Signature of ApplicantlTenant <br /> <br />Date <br /> <br />The individual named directly above is an applicant/tenant of a housing program that requires verification of income. The information provided will <br />remain confidential and will be used solely for the purpose of determining eligibility for occupancy. Your prompt response is crucial and greatly <br />appreciated. <br /> <br />Signature of Owner's Representative <br /> <br />Return Form To: <br /> <br /> <br />Market Value: <br /> <br />$ <br /> <br />Cash Value"': <br /> <br />Number of Units (i,e, shares): <br /> <br />Owned: <br /> <br />at $ <br /> <br />per unit <br /> <br />Dividends Paid and/or Interest Rate (this includes reinvested interest/dividends): $ <br />(Tfvaries, please use average dividend paid and/interest rate, or the rate at the close of business yesterday) <br /> <br />% <br /> <br />Frequency of Interest/Dividend payments: <br /> <br />D Monthly DQuarterly DSemi-annual D Annually D Other <br /> <br />"'Cash Value is the current value less the cost to turn the asset into cash. <br /> <br />Additional Remarks: (please indicate any anticipated changes.) <br /> <br />Signature <br /> <br />Printed Name & Title <br /> <br />Date <br /> <br />Financial Institution Name and Address <br /> <br />Phone # <br /> <br />Fax # <br /> <br />E-mail <br /> <br />NOTE: Section 1001 of Title 18 oflhe U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Departmenl or Agency of the <br />Uniled States as to any matter within its jurisdiction. (Updated 11107) <br />