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201109462 <br /> SOCIAL SECURITY VERIFICATION <br /> _ , ,.; . � ;t _. . <br /> "..' `THISwEGTION T.(?$E C(:?MPLE1'ED BY'I�NANT AND EXECUTED BY MANAGEIvIEN�" A <br /> �� :..... ��., �,.: <br /> TO: <br /> Name and Address of Social Security Administration Phone Number <br /> Fax Number <br /> RE: <br /> ApplicandTenant Name Social Security Number <br /> Unit#(if assigned) <br /> I hereby authorize release of my Social Security information. <br /> Signature ef ApplicandTenant Date <br /> The individual named directly above is an applicantltenant of a housing program that requires verification of income.The information provided will <br /> remain confidential and will be used solely for the purpose of determining eligibility for occupancy.Your prompt response is crucial and greatly <br /> appreciated. <br /> Signah�re of Owner's Representative <br /> Return Form To: <br /> � ��° T�IIS SEGTIU`N'I'O BE��MPi.ETEB B�APPROPRIATE SOCIAL�E�[71tI'I'Y P�RS4 �L�" ` <br /> ❑ The gross amount of the monthly Social Security Benefit is(do not subtract Medicare deduction) $ <br /> The above amount became effective / <br /> Month%Year <br /> ❑ The monthly payment of the Supplemental Security Income payment is � <br /> The above amount became effective / <br /> Month/Year <br /> ❑ Other information needed: <br /> Complete only if you are unable to verify information requested: <br /> ❑ Claim Still Pending <br /> ❑ No record based on identifying information <br /> ❑ Other <br /> Social Security Official's Signature Printed Name Date <br /> Social Security Administration's Name and Address <br /> Phone# Fax# E-mail <br /> NOTE: Section]001 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 to any matter within its jurisdiction. (Updated 12/10) <br />