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<br />200809274 <br /> <br />VERIFICA nON OF UNEMPLOYMENT BENEFITS <br /> <br />2oVQW68 <br /> <br /> <br />TO: <br /> <br />Name & Address of Agency <br /> <br />Phone Number <br /> <br />Fax Number <br /> <br />IRE: <br /> <br />Applicant/Tenant Name <br /> <br />Social Security Number <br /> <br />Unit # (if assigned) <br /> <br />I hereby authorize release of my unemployment information. <br /> <br />Signature of Applicant/T enant <br /> <br />Date <br /> <br />The individual named directly above has indicated that he or she is receiving benefits from your agency and is an applicant/tenant of a housing <br />program that requires verification of income. The information provided will remain confidential and will be used solely for the purpose of <br />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 />Gross weekly payment to client $ <br /> <br />Beginning date of payment <br /> <br />Ending date, if known <br /> <br />Is this client entitled to an extension of benefits? YES 0 <br /> <br />NO 0 <br /> <br />If yes, for how long? <br /> <br />Signature <br /> <br />Printed Name & Title <br /> <br />Date <br /> <br />Agency's Name and Address <br /> <br />Phone # <br /> <br />Fax # <br /> <br />E-mail <br /> <br />NOTE: Section 100 I of Title 18 of thc 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 11/07) <br />