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201109462 <br /> CLARIFICATION RECORD <br /> Applicant/Resident Name: Date: <br /> ❑ Initial Certification Date of Expected Move-In: <br /> ❑ Recertification(Annual or Interim) Effective Date: <br /> Means of Clarification: ❑ Phone Conversation <br /> ❑ Person-to-Person Conversation <br /> ❑ Other: <br /> (Please state) <br /> Date of Clarification: Time: <br /> Contact Name: Position: <br /> Company/Organization: Phone: <br /> Summary Clarification Requested: <br /> Explanation or Clarification Given: <br /> Signature of Contact Printed Name Date <br /> Signature of Owner's Representative Printed Name Date <br /> (Updated(12/10) <br />