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<br />200809274 <br /> <br />VERIFICATION OF SOCIAL SERVICES <br /> <br />2ValD968 <br /> <br /> <br />TO: <br /> <br />Name & Address of Agency <br /> <br />Phone Number <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 services information. <br /> <br />Signature of Applicant/Tenant <br /> <br />Date <br /> <br />The client named directly above has indicated that he or she is receiving income from your agency. The information provided will remain confidential and <br />will be used solely for the purpose of determining eligibility for occupancy. Your prompt response is crucial and greatly appreciated. <br /> <br />Signature of Owner's Representative <br /> <br />Return Form To: <br /> <br /> <br />Monthly payment from this Agency: <br /> <br />T ANF / AFDC <br /> <br />General Assistance <br /> <br />Child Support Pass Through <br /> <br />Other <br /> <br />Other known income <br /> <br />Remarks-Please indicate any anticipated changes in: <br /> <br />(I) The monthly payment: <br /> <br />(2) The family status of the Applicant: <br /> <br />Social Worker's Signature <br /> <br />Social Worker's Printed Name <br /> <br />Date <br /> <br />Agency Name and Address <br /> <br />Phone # <br /> <br />Fax # <br /> <br />C-mail <br /> <br />NOTE: Section 1001 of Title 1 R 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 Statcs as to any matter within its jurisdiction. (Updated 11/07) <br />