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201109462 <br /> VERIFICATION OF SOCIAL SERVICES <br /> ��.. .�;� �,. <br /> � THIS.SEG'TION�TO B�CQMPLETED SY"PEIVANT AND,EXECUTED BY MANAGEMENT.", �-� <br /> ;.. c,,. °�° <br /> ,.,. . . <br /> .t. � <br /> , <br /> �.,�- � <br /> „_ �� <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 my social services information. <br /> Signature of ApplicanUTenant Date <br /> The client named directly above has indicated that he or she is receiving income from your agency.The information provided will remain confidential and <br /> will be used solely for the purpose of determining eligibility for occupancy.Your prompt response is crucial and greatly appreciated. <br /> Signature of Owner's Representative <br /> Return Form To: <br /> �`' �� � , � ,� <br /> �, � ��' � �rs s�c��Qri"�r4��ca��,��n��`:aG�r�,���� <br /> �.� � <br /> Monthly payment from this Agency: <br /> TANF/AFDC General Assistance <br /> Child Support Pass Through — <br /> Other <br /> Other known income <br /> Remarks-Please indicate any anticipated changes in: <br /> (1) The monthly payment: <br /> (2) The family status of the Applicant: <br /> Social Worker's Signature Social Worker's Printed Name Date <br /> Agency Name and Address <br /> Phone# Fax# E-mail <br /> �'OTE: Section 1001 of Title 18 of the U.S.Code makes it a criminal offense to make willful false statements or misrepresentations to any DepaRment or Agency of the <br /> United States as to any matter within its jurisdictioa (Updated 12/]0) <br />