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<br />200809274 <br /> <br />SA VINGS BONDS VERIFICA nON <br /> <br />20VOID68 <br /> <br /> <br />TO: <br /> <br />Name & Address of Financial Institution <br /> <br />Phone Number <br /> <br />Fax Number <br /> <br />RE: <br /> <br />Social Security Number <br /> <br />Applicant/Tenant Namc <br /> <br />Unit # (if assigned) <br /> <br />I hereby authorize release of my asset information. <br /> <br />Signature of Applicant/Tenant <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 />Bond Serial Number: <br /> <br />Denomination: $ <br /> <br />Series: <br /> <br />D EE Bond D I Bond D E Bond D Savings Notes <br /> <br />Issue Date: <br /> <br />Final Maturity: <br /> <br />Interest Rate: <br /> <br />Value of Bond: <br /> <br />$ <br /> <br />Note: <br /> <br />D Not Issued D Not eligible for payment D Includes 3 month interest penalty D Matured and not earning interest <br /> <br />Additional Remarks: (please indicate any anticipated changes.) <br /> <br />Signature <br /> <br />Printed Name & Title <br /> <br />Date <br /> <br />Bank Name and Address <br /> <br />Phone # <br /> <br />Fax # <br /> <br />E-mail <br /> <br />NOTE: Section 1001 of Tille 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Depal1lnent or Agency of the <br />United States as to any mailer within its jurisdiction. (Updated 11/07) <br />