Phone: / Fax: / Phone: / Fax:
We are required to verify the assets of applicants/residents living in affordable housing. To comply with this requirement, we ask your cooperation in supplying the information requested below regarding the referenced applicant/resident. Information provided will remain confidential. Please complete and return this form as soon as possible. If sent by mail, a stamped, self-addressed return envelope is enclosed. If sent by fax/e-mail, please use the fax number/e-mail address listed above. If you have any questions please call the telephone number listed above.
Owner/Owner’s Agent Signature: / Date:
RE: Applicant/Resident:
Social Security Number: / Account #(s):
Applicant/Resident: You do not have to sign this form if either the requesting organization (property name, address, and phone/fax) or the organization (company name, address, and phone/fax) 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 twelve (12) months. There are circumstances which would require the Owner to verify information that is up to five (5) years old which would be authorized by me on a separate consent attached to a copy of this consent.
Applicant/Resident Signature: / Date:
INFORMATION REQUESTED: Please include any jointly held accounts. *Please answer this question based on the income the asset is currently generating.
Checking/Draft Account(s):
Account Holder / Account Number / Average 6 Months Bal / Annual % or Dividends * / Withdrawal Penalty $/%
Savings/Share/Certificate of Deposit Account(s):
Account Holder / Account Number / Present Balance / Annual % or Dividends * / Withdrawal Penalty $/%
401K Plan/Annuity/IRA/Pension/Retirement Account(s)/Mutual Funds/Stock/Bonds/Money Market/Securities:
Does Applicant/Resident have access to the Retirement Account prior to termination or retirement? Yes No.
Account Holder / Account Number / Present Balance / Annual % or Dividends * / Original Date / Withdrawal Penalty $/% / Divestiture Cost
TRUST/BURIAL FUNDS:Complete Revocable or Irrevocable Section as applicable
Revocable
The Applicant/Resident is the: (check one) Beneficiary Grantor of the Trust/Fund
Value of Trust/Fund Administered:$______
Anticipated Amount of Income to be Earned by Trust/Fund over next 12 months:$______
Is the Amount: (check one) Reinvested Disbursed / Irrevocable
The Applicant/Resident is the: (check one) Beneficiary Grantor of the Trust/Fund
Value of Trust/Fund Administered:$______
Anticipated Amount of Income to be Earned by Trust/Fund over next 12 months:$______
Is the Amount: (check one) Reinvested Disbursed
PENALTIES FOR MISUSING THIS FORM
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, RHS, Section 42, the PHA and any owner (or any employee of HUD, RHS, Section 42, the PHA 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, RHS, Section 42, the PHA 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).
Printed name of person supplying the information: / Printed title of person supplying the information:
Signature: / Date: / Telephone:
Asset Verification (10/12) Page 1 of 1 TC-15