Kentucky Housing Corporation

HOMELESS AND HOUSING COALITION OF KENTUCKY

HOUSING NOW PROGRAM

Third Party Verification Information Form

Homeless Housing Coalition of Kentucky must complete third party verification on all participants of the Housing Now Program. Please complete the following information for this process to be completed in a timely manner. This form is be forwarded when submitting the Personal Declaration.

Tenant Name: ______

Unit Address: ______

Mailing Address: ______

A. INCOME VERIFICATION:

Does the participant have income: YesNo

If the participant has income please complete the following:

Income Source # 1: ______

Income Source Address: ______

______

Income Source Telephone Number: (______)______

Income Source Fax Number: __( )______

Income Source # 2: ______

Income Source Address: ______

______

Income Source Telephone Number: (______)______

Income Source Fax Number: __( )______

If the participant has additional incomes please copy this page and complete the information.

B. BANKING INFORMATION:

Does the participant have a bank account? Yes No

If the participant has any type of bank accounts please complete the following:

Name of Bank:______

Address of Bank: ______

______

Bank Telephone #: ___(______)______

Income Source Fax Number: __( )______

Type of Account:______

Type of Account: ______

If the participant utilizes different Banks please copy and complete information for each Bank.

C. MEDICAL EXPENSE VERIFICATION

Does the participant have monthly out of pocket expense for medical care: Yes No

If the participant has monthly out of pocket expenses for medical care please complete the following:

MEDICAL EXPENSES

Name of Physician: ______

Address of Physician: ______

______

Physician’s Telephone: ____( )______

Fax Number: __( )______

Name of Physician: ______

Address of Physician: ______

______

Physician’s Telephone: ____( )______

Name of Pharmacy:______

Address of Pharmacy: ______

______

Pharmacy’s Telephone: __(______)______

Name of Pharmacy:______

Address of Pharmacy: ______

______

Pharmacy’s Telephone: __(______)______

Fax Number: __( )______

If the participant has additional physicians/pharmacies please copy and complete.

D. INFORMAL SUPPORT

Does any one assist the participant with his/her bills or gives him/her money on a regular basis:

Yes No

If the participant receives financial assistance please complete the following:

Name of person offering financial assistance: ______

Mailing Address of person offering financial assistance:______

______

Name of person offering financial assistance: ______

Mailing Address of person offering financial assistance:______

______

If the participant has additional individuals assisting him/her please copy and complete.

______

Participant’s SignatureDate

______

Participant’s SignatureDate

Housing Now Program Third Party Verification7/1/2011