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201109462 <br /> CHILD SUPPORT AND/OR ALIMONY VERIFICATION <br /> (Completed by Payer) <br /> ,. <br /> �� 7'HTS;SEGTI4l3.T0 BE GC►IvIPLE'TED`BY'�ENANT'AND EX�CUTED BI��MANAGEMENT , <br /> � <br /> � � - � __. � . .� <br /> , <br /> TO: <br /> Name&Address of Payer Unit#(if assigned) <br /> RE: <br /> ApplicandTenant Name Social Security Number <br /> I hereby authorize release of my child supportlalimony information. <br /> Signature of ApplicandTenant Date <br /> The individual named directly above has indicated that he or she is receiving support and is an applicanUtenant of a housing program that requires <br /> verification of income. The information provided will remain confidential and will be used solely for the purpose of determining eligibility for occupancy. <br /> Your prompt response is crucial and greatly appreciated. <br /> Signature of Owner's Representative _. <br /> Return Form To: <br /> `;~ '��'�" 'THIS SE��'It�I�T0 B�CC?1Vr1'I,ETED BY;�AYER .. �`��` � <br /> ��,� ` .�.,. ��, <br /> This will certify that I pay$ per in child support to(Name): <br /> for the support of Child(ren)Name(s): <br /> This will certify that I pay$ per in alimony to(Name): <br /> Signature Printed Name Date <br /> NOTE: Section 1001 of Tide 18 of the U.S.Code makes it a criminal offense to make wiliful false statements or misrepresentations to any Department or Agency of the <br /> United States as to any matter within its jurisdiction. (Updated 12/10) <br />