201109462 - Laserfiche WebLink

Browse

TRUST ACCOUNT VERIFICATION 201109462 �t,;, THIS SEG'T'ION TD B�GOMPL.ETED BY T'ENANT�`ANT3 EXECUTELI BY MANAGEMENT ,. �.:; TO: Name&Address of Financial Institution Phone Number Fax Number RE: ApplicanUTenant Name Social Security Number Unit#(if assigned) I hereby authorize release of my trust account information. Signature of ApplicanUTenant Date The individual named directly above is an app?icantltenant 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 orompt response is crucial and greatly appreciated. Signature of Owner's Representative Return Form To: `'� ` TxiIS�S�CTION�TO�FSE��OM1'L�TEb BY FINAI�ICIAL INSTIT'I1TT W �: . ,, OI�',. ��°:� � . . �� ,:,,.'� . .�.� �,:.� „�s- - � �,;, ,,.. �. Trust Account Number: Date Established: Is the applicant the grantor or the beneficiary? ❑ Grantor ❑ Beneficiary ❑ Both What type of trust is this? ❑ Revocable ❑ Irrevocable Cash Value*: $ Market Value: $ Does the applicandtenant have access to the lump sum amount in the trust? ❑Yes ❑No Is the applicant/tenant receiving periodic payments?❑Yes ❑No If yes,what amount: $ Frequency: Is the trust earning interest and/or dividends? ❑Yes ❑No If yes,what amount: $ / % Frequency: (this includes reinvested interest/dividends) *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 ot�'ense to make willful false statements or misrepresentations to any Department or Agency of the United States as to any matter within its jurisdictioo. (Updated 12/]0)