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<br />200809274 <br /> <br />SOCIAL SECURITY VERIFICATION <br /> <br />2M€lID68 <br /> <br /> <br /> <br />TO: <br /> <br />Phone Number <br /> <br />Name and Address of Social Security Administration <br /> <br />Fax Number <br /> <br />RE: <br /> <br />Social Security Number <br /> <br />Applicant/Tenant Name <br /> <br />Unit # (if assigned) <br /> <br />I hereby authorize release of my Social Security information. <br /> <br />Signature of Applicant/Tenant <br /> <br />Date <br /> <br />The individual named directly abovc is an applicant/tenant ofa housing program that requires verification of income, The information provided will <br />remain confidential and will be used solely lor 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 />o The gross amount of the monthly Social Security Benefit is (do not subtract Medicare deduction) <br /> <br />$ <br /> <br />The above amount became effective _I _ <br />Month 1 Year <br /> <br />o The monthly payment of the Supplemental Security Income payment is <br /> <br />$ <br /> <br />The above amount became etTecti ve _I _ <br />Month 1 Year <br /> <br />o Other information needed: <br /> <br />Complete only if you are unable to verify information requested: <br /> <br />o Claim Still Pending <br />o No record based on identifying information <br />o Other <br /> <br />Social Security Otlicial's Signature <br /> <br />Printed Name <br /> <br />Date <br /> <br />Social Security Administration's Name and Address <br /> <br />Phone # <br /> <br />Fax # <br /> <br />E-mail <br /> <br />:'IIOTK; Section 1001 of Title 18 of the U.S. Code makes it 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 11107) <br />