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RETIREMENT SAVINGS PLAN VERIFICATION 201109462 (401 K,IRA,Keogh,etc.) , - .� �" Ti-IIS SECTION TO BE COI4IPLE'1`ED,.BY TEh7ANT,AND E?CECLJTED�BY'MANA�EMENT ,:; � .� � ; TO: Name&Address Phone Number Fax Number RE: ApplicanUTenant Name Social Security Number Unit#(if assigned) I hereby authorize release of my retirement account information. Signature of ApplicanUTenant Date The individual(s)named directly above is an applicant/tenant of a housing program that requires verification of income.The information provided will remain confidential 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'I"ION TO BE COIvfPT��TEt?BX�RETII2EMEI�T PL�PRO�DER � � § ��y. 'S . 3 � �� „�4, !�.F Does the holder have access to the lump sum amount? ❑Yes ❑No Type of account: Cash Value*: $ Market Value: $ Is the applicandtenant receiving periodic payments? ❑Yes ❑No If yes,what amount: $ Frequency Is this savings plan eaming interest and/dividends?❑Yes ❑No If yes,what amount: % / $ Frequency (this includes reinvested interesUdividends) *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 Name an A ress P�one# Fax# E-mai NOTE: Section 1001 of Tide 18 of the U.S.Code makes it a criminal offense ro 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)