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<br />200809274 <br /> <br />2oV~I~8 <br /> <br />WORKERS COMPENSATION VERIFICATION <br /> <br /> <br /> <br />TO: <br /> <br />Name & Address of Agency <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 workers compensation information. <br /> <br />Signature of ApplicantlTenant <br /> <br />Date <br /> <br />The individual namcd directly above has indicated that he or she is receiving payment for you and is an applicant/tenant ofa housing program that <br />requires verification of income. The information provided will remain confidential and will be used solely for the purpose of determining eligibility <br />tur occupancy. Your prompt response is crucial and greatly appreciated. <br /> <br />Signature of Owner's Representative <br /> <br />Return Form To: <br /> <br /> <br />Weekly <br /> <br />D <br /> <br />Monthly <br /> <br />D <br /> <br />Payments to Employee $ <br /> <br />Weeks or amount still to be paid <br /> <br />Effective Date <br /> <br />Ending Date, if known <br /> <br />Additional Remarks: (please indicate any anticipated changes.) <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 1001 of Title 18 ofthc U.S. Code makes it a criminal otlense 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 />