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201109462 CHILD SUPPORT AND/OR ALIMONY VERIFICATION (Completed by Clerk of Court or Appropriate Verifying State Agency) `F�` THIS SEG'TIt7NT()BE GOMP`LETED BY TE�IANT'. '_ ; . _ . :: . , � �AND EXECLTTED,BY�MAI� �EMEI�F`Ta' �'� �� - � , , �v� . . �.,. .. ..; +�-... M� _ �,..,€�:. . _ TO: Name&Address of Agency Unit#(if assigned) Docket Page# RE: ApplicanUTenant Name Social Security Number I hereby authorize release of my child suppordalimony information. Signature of ApplicantlTenant Date Child's Name Child's Name Child's Name Child's Name The individual named directly above has indicated that he or she is receiving court-ordered support and is an applicanUtenant of a housing program that requires verification of income. The information provided will remain confidentia]and will be used solely for the purpose of determining eligibility for occupancy.Your prompt response is crucial and greatly appreciated. Signature of Owner's Representative Return Form To: THIS:SEC't'IO�TO HE'COIVIPLET'�17.; � � � �,�.,- �Y�I.ERK OF GOURT.C3B AP�?Itf)FRIATE•'V�TtI�II�TC`i STAT�AGENCY a�� • a�s. ,.. � � ��_ _ � �� _�� This will certify that the above named person is court ordered to receive$ per in child support and/or$ per in alimony. (A copy of the account ledger may be substituted.) Clerk of Court or Agency Official's Signature Printed Name&Title Date Agency's Name and Address Phone# Fax# E-mail NOTE: Section]001 of Tide 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 matter within its jurisdiction. (Updated 12/]0)