SOCIAL SECURITY BENEFITS VERIFICATION

 

 

THIS SECTION TO BE COMPLETED BY MANAGEMENT AND EXECUTED BY APPLICANT/TENANT

 

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).

 

R Return Form to:

 

 

 

 

 

  Applicant/Tenant Signature          

           

Printed Name of Applicant/Tenant          

           

Date     Social Security #

 

 

THIS SECTION TO BE COMPLETED BY SOCIAL SECURITY ADMINISTRATION

 

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.

 

 

PLEASE COMPLETE THE FOLLOWING:

 

Date of Initial Award:        

 

Current GROSS Monthly Benefit:  $        

Effective Date of Current Benefit:          

Medical Insurance Premiums:   $        

(deducted from gross benefit)

 

Upcoming COLA Increase Amount:   %    or  q  Unknown

Effective Date of Upcoming COLA:            

 

 

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

 

Verifier’s Signature:

 

Date:

 

Printed Name:

 

Phone:

 

 

Title:

   

 

 

 

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.