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MUTUAL FUNDS/STOCK/BONDS VERIFICATION 201109462 ,.. ��„ . ,,�t, � � � �.� .,.. _ ., = ,.THIS'�ECTION TQ-BE CqIvIPLETEII BY TENANT ANL�EXE�UTEA BY MANAGEMENT,: £a=� _ ~ TO: Name&Address of Financial Institution Phone Number Fax Number RE: ApplicanbTenant Name Socia]Security Number Unit#(if assigned) I hereby authorize release of my asset information. Signah�re of Applicant/Tenar.t Date The individual named directly above is an applicanUtenant of a housing program that requires verification of income.The inforrnation provided will remain confidential and will be used solely for the purpose of determining eligibility for occupancy.Four prompt response is crucial and greatly appreciated. Signature of Owner's Representative Return Form To: i_ . ., 1. . . .. ,.. ; � � �, ,THTS�S��CTTO�T TO BE`'��MPLET�17 B'Y,�FINAN� �INS7'3TUTIf7N �� .�, ,E. �: �,. Market Value: $ Cash Value*: Number of Units(i.e. shares): Owned: at $ per unit Dividends Paid and/or Interest Rate(this includes reinvested interesddividends): $ / % (If varies,please use average dividend paid and/interest rate,or the rate at the close of business yesterday) Frequency of InteresdDividend payments: ❑Monthly ❑Quarterly ❑Semi-annual ❑Annually ❑Other *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 matter withi�itsjurisdiction. (Updated 12/]0)