Laserfiche WebLink
201109462 <br /> FOSTER CARE VERIFICATION <br /> (For use in verifying full time student eligibility) <br /> u ��_ � , ; ,,: <br /> ,. <br /> .,.. <br /> ;..< <br /> " -'�FTIS_S�GTIUN T'Q BE C(tI�+IPLETFD BY'T�NAN'�AI�b EXECU'�ED�Y MAI�TI�G�M�N'C '�' � ' � � <br /> � � <br /> �. _: , , <br /> x. ,a-:- �. � _ < <br /> TO: <br /> Name&Address of Agency Phone Number <br /> Fax Number <br /> RE: <br /> ApplicanUTenant Name Social Security Number <br /> Unit#(if assigned) <br /> I hereby authorize release of the requested information. <br /> Signature of ApplicanUTenant Date <br /> The individual named directly above is an applicanUtenant of housing program that provides an exemption from a prohibition against full time <br /> students if the student was previously in foster care. The information provided will remain confidential to satisfaction of that stated purpose only. <br /> Your prompt response is crucial and greatly appreciated. <br /> Signature of Owner's Representative <br /> Return Form To: <br /> w. <br /> � , r� �.: �; �� �` �� <br /> ��"; , ; TH755�C'�IQI�'�C)BE"GOMPLE'[`ED;BY:AGBN�Y �� � ' <br /> _ �u <br /> ,: <br /> . <br /> -, . „ ,u���_ <br /> - ._ .�i. -- � .. __ ' __ = ,,, . .. , m , .a .. - `� f <br /> For purposes of determining the eligibility of full time students formerly out-of-home placement in a foster care system governed <br /> by Title N,part B or E of the Social Security Act Foster Care Eligibility Program,the above referenced individual: <br /> ❑ Has previously been in foster care from to <br /> ❑ Has not previously been in foster care <br /> Additional remarks: <br /> Agency's Signature Agency's Printed Name Date <br /> Agency Name and Address <br /> Phone# Fax# E-mail <br /> 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 <br /> United States as ro any matter within its jurisdiction. (Updated 12/]0) <br />