EMPLOYMENT TERMINATION VERIFICATION

This Verification is being delivered in connection with the undersigned's eligibility for residency in the following community:

Project Name:                Unit Number (if assigned):      

Building Address:                          

I hereby authorize release of my employment information for                

                   Name of Employer

Applicant/Tenant Signature          

Printed Name of Applicant/Tenant          

Date     Social Security #

The above-named individual has applied for residency or is currently residing in housing that requires verification of employment or termination of employment. Please provide the information requested below and return it to the address or fax number listed above.

Date of Hire:    Date of Termination:      Last day worked:  

Do you anticipate rehiring this employee?    q Yes    q No    If yes, when?      

Will the employee be eligible for Unemployment Benefits?  q Yes    q No    If yes, when?        

Will the employee receive additional paychecks from Workman's Compensation?  q Yes    q No

If YES, provide the name and address of the company through which this can be verified: ___________________________________

 _____________________________

 _____________________________

Total Severance Pay anticipated for the next 12 months:  $    q N/A

I hereby certify that the information supplied in this section is true and complete to the best of my knowledge.

Organization/Firm:  

NOTE: Section 1001 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.