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201109462 <br /> WORKERS COMPENSATION VERIFICATION <br /> x <br /> ✓ 'FHIS�SEG'TI03�1�TO�BE CQMPL,ETED BY TENANT.ANU E7CE�UTEI�B"4'MAI�'AGE�NT �R <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 he�cby authorize release of my workers compensation information. <br /> Signature of ApplicanUTenant Date <br /> The individual named directly above has indicated that he or she is receiving payment for you and is an applicandtenant of a housing program that <br /> requires verification of income.The information provided will remain confidential and will be used solely for the purpose of determining eligibility <br /> for occupancy.Your prompt response is crucial and greatly appreciated. <br /> Signature of Owner's Representative <br /> Return Form To: <br /> ��� ��` "����� TH75r5�CTTON�'0 BE;�pMPI;ETED BY APPROPRTATE AGENCY` ���� .��y.�� <br /> `�, t�: �..a'�. ��� � <br /> Weekly ❑ Monthly ❑ Payments to Employee$ <br /> Weeks or amount still to be paid <br /> Effective Date Ending Date,if known <br /> Additional Remarks: (please indicate any anticipated changes.) <br /> Signature Printed Name&Title Date <br /> Agency'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/]0) <br />