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<br />200809274 <br /> <br />RETIREMENT SAVINGS PLAN VERIFICATION <br />(401K, IRA, Keogh, etc.) <br /> <br />2~~68 <br /> <br /> <br />TO: <br /> <br />Name & Address <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 retirement account information. <br /> <br />Signature of Applicant/Tenant <br /> <br />Date <br /> <br />The individual(s) 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 />Does the holder have access to the lump sum amount? DYes D No <br /> <br />Type of account: <br /> <br />Cash Value*: $ <br /> <br />Market Value: $ <br /> <br />Is the applicant/tenant receiving periodic payments? DYes D No <br /> <br />!fyes, what amount: $ <br /> <br />Is this savings plan earning interest and! dividends? DYes D No !fyes, what amount: $ <br />(this includes reinvested interest/dividends) <br /> <br />% <br /> <br />Frequency <br />Frequency <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 />Pnnted Name & Title <br /> <br />Date <br /> <br />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 otlense to make willful false statemems Or misrepresentations to any Departmem or Agency ofthe <br />United States as to any matter within its jurisdiction. (Updated 11/07) <br />