201109462 - Laserfiche WebLink

Browse

201109462 VERIFICATION OF UNEMPLOYMENT BENEFITS _ ,. �P, �z_ ,�„ -� . � �� , ,: , �,� ` �,� THTS;SECTTON'T�BE Cf�MPLE'I'ED.BY TENANT t1NI7 EXCUTED SY MANAGEIVIENT �: �. . � . . � �,_ .. _: � ,: _<<,_. — . �� - _� _�,�_ - � -b. TO: Name&Address of Agency Phone Number Fax Number � RE: Applicant/Tenant Name Social Security Number Unit#(if assigned) I hereby authorize release of my unemployment information. Signature of Applicant/Tenant Date The individual named directly above has indicated that he or she is receiving benefits from your agency and is an applicandtenant of a housing prob am 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 appreciatcd. Signature of Owner's Representative Return Form To: ' � � �THTS SECTTCI7��;O BE'�t)M7'LE'1`ET�B'i'`APPROPRIA'I'�AG�N�'Y " „� -_��- .� , . .. ��.: _ ,.�, �. £ Gross weekly payment to client$ Beginning date of payment Ending date,if known Is this client entitled to an extension of benefits? YES ❑ NO ❑ If yes,for how long? Signature Printed[Vame&Title Date Agency's Name and Address Phone# Fax# E-mail VOTE: 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 United States as to any matter within its jurisdiction. (Updated 12/]0)