Verification of Recurring Cash Contributions
VERIFICATION OF: Recurring Cash Contributions
|(Name of HOME Participating Jurisdiction) |Purpose of Cash Contribution: |
|AUTHORIZATION: Federal Regulations require us to verify Recurring |_____________________________________ |
|Cash Contributions made to all members of the household applying for |_____________________________________ |
|participation in the HOME Program which we operate and to reexamine |_____________________________________ |
|this income periodically. We ask your cooperation in supplying this |_____________________________________ |
|information. This information will be used only to determine the |Amounts anticipated to be received during the next |
|eligibility status and level of benefit of the household. |12 months: |
|Your prompt return of the requested information will be appreciated. |Date: _______________________ $_________ |
|A self-addressed return envelope is enclosed. |Date: _______________________ $_________ |
| |Date: _______________________ $_________ |
| |Date: _______________________ $_________ |
| |Date: _______________________ $_________ |
| |Date: _______________________ $_________ |
| |Date: _______________________ $_________ |
| |Date: _______________________ $_________ |
| |Date: _______________________ $_________ |
| |Date: _______________________ $_________ |
| |Date: _______________________ $_________ |
| |Date: _______________________ $_________ |
|RELEASE: I hereby authorize the release of the requested information.|Signature of __________________________ or Authorized Representative |
|_____________________________________ |_____________________________________ |
|(Signature of Applicant) |Title: ________________________________ |
|Date: ________________________________ |Date: ________________________________ |
|Or a copy of the executed “HOME Program Eligibility Release Form,” |Telephone: ___________________________ |
|which authorizes the release of the information requested, is | |
|attached. | |
|WARNING: 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. |
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