Alternate Form of Verification of Employment

NHE, INC.

ALTERNATE FORM OF VERIFICATION OF EMPLOYMENT

DATE:
TO: / FROM:

RETURN THIS VERIFICATION TO THE PERSON LISTED HERE

SUBJECT: Verification of Information Supplied by an Applicant for Housing Assistance

NAME:
ADDRESS:

The Department of Housing and Urban Development (HUD) requires verification of information received from a person receiving assistance. We are writing to ask you to verify certain information about the person listed above who is a recipient of housing assistance from a HUD program.

The information we require has been listed below. We request that you fill in the necessary information and return it to the person listed at the top of this letter as quickly as possible. Your prompt attention to this matter will ensure that there is no delay in the processing of assistance payments. Consent to release this information has been received from the party involved.

INFORMATION BEING REQUESTED

1. / Dates of Employment: / From / To
Actual Date Applied for position:
2. / Employee is paid:
hourly / rate per hour / $ / Average hours per week
overtime per hour / $ / Average hours per week
monthly / $
weekly / $
other / $
3. / Additional employment income (tips, bonus, etc.):
Type of income / $ / amount
Type of income / $ / amount
4. / Recent changes in employment income (increase or decrease):
increase / $ / amount / date of change
decrease / $ / amount / date of change
4. / Please check one of the following to indicate type of employment:
Permanent-Full-Time / Seasonal-Full-Time
Permanent-Part-Time / Seasonal-Part-Time
5. / If the person’s employment has been terminated, please enter the date of termination and the reason for termination:
Date of termination:
Reason:
NAME AND TITLE OF PERSON / FIRM/ORGANIZATION
SUPPLYING THE INFORMATION
TELEPHONE NUMBER / FAX NUMBER
SIGNATURE / DATE

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YOU DO NOT HAVE TO SIGN THIS FORM IF EITHER THE REQUESTING ORGANIZATION OR THE ORGANIZATION SUPPLYING THE INFORMATION IS LEFT BLANK.

RELEASE: I hereby authorize the release of the requested information. Information obtained under this consent is limited to information that is no older than 12 months. There are circumstances which would require the owner to verify information that is up to 5 years old, which would be authorized by me on a separate consent attached to a copy of this consent.

SIGNATURE / DATE

PENALTIES FOR MISUSING THIS CONSENT:

Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD, and any owner or (or any employee of HUD, or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the **Social Security Act at 208 (a) (6), (7) and (8). Violation of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).**

C-11 Verification of Employment Income Form 1 of 1 December 2013 REV