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201109462 ANNUITY VERIFICATION ; � . ,.,, .. � ,'`; •' THTS`SECT.ItjN'Tl?'B�COlV11'�,E1"EI7 BY TENANT?iND��XECUTED BY MA�IAGEMENT a�.� � � .�� ' - TO: Name&Address of Financial Institution Phone Number Fax Number RE: ApplicanUTenant Name Social Security Number Unit#(if assigned) I hereby authorize release of my annuity information. Signature of Applicant/Tenant Date The individual named directly above is an applicant/tenant of a housing program that requires verification of income.The information provided will remain confidential and will be used solely for the purpose of determining eligibility for occupancy.Your prompt response is crucial and Sreatly appreciated. Signature of Owner's Representative Return Form To: � ��:� _. � . � ;; �� � , TFII�SEC'�'IOI��O$E C�Mi'i.ETEI3 B�FINA3�TCIA�I�+I�Ti'�.�T'I�N� . � � J_ .�� ` �<, � Type of Annuity held: ❑Fixed ❑Variable ❑Hybrid ❑ Immediate ❑ Life ❑Other CurrendMarket Value: $ Cash Value*: $ Does the applicandtenant have access to the lump sum amount in the annuity? ❑Yes ❑No Is the applicanbtenant receiving periodic payments?❑Yes ❑No If yes,what amount: $ Frequency: Is the annuity earning interest and/or dividends? ❑Yes ❑No If yes,what amount: %/$ Frequency: (this includes reinvested interesUdividends) *Cash Value is the current value less the cost to turn the asset into cash. Additional Remarks: (please indicate any anticipated changes.) Signature Printed Name&Title Date Financial Institution Name and Address Phone# Fax# E-mail NOTE: 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 United States as to any matterwithin its jurisdiction. (Updated 12/10)