PERIODIC MONETARY ASSISTANCE 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:                          

By my signature, I hereby authorize disclosure of the information requested below in order to determine my eligibility to rent as required by 24 CFR 92 (Code of Federal Regulations).

  Applicant/Tenant Signature          

Printed Name of Applicant/Tenant          

Date     Social Security #

THIS SECTION TO BE COMPLETED BY AGENCY/PERSON PROVIDING ASSISTANCE

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

1.  I/We provide $       per q week q month q year in cash assistance to the above-named person and will continue to do so for the next     months.

2.  I/We purchase, or expect to purchase, items for the benefit of the above-named person. The following is a description of the items purchased and the anticipated annual cost:

 Description:                          

 Annual Cost: $      

3.  I/We pay for, or expect to pay for, household expenses, including utilities for the benefit of the above-named person. The following is a description of the household expenses to be paid and the anticipated annual cost:

 Description:                          

 Annual Cost: $      

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

Relationship to Applicant/Tenant:      

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.