PENSION/RETIREMENT/ANNUITY INCOME
PENSION/RETIREMENT/ANNUITY INCOME
Name SSN
Address City State Zip
The person referenced above is a participant in a project funded by the HOME Investment Partnerships Program. The U.S. Department of Housing and Urban Development (HUD) requires that we verify the income of program participants. Please complete all the information below. Thank you for your assistance.
By signing below I authorize the release of this information.
Signature of Client Date
| |
|Benefit Amount |
| |
|Amount of Monthly Payments to Participant: $_______________ |
|OR |
|Amount of Weekly Payments to Participant: $_______________ |
| |
|Date Payments Began: ________________ Ending Date of Payments: _______________ |
| |
|Deductions from Gross for Medical Insurance Premiums: $________________ |
| |
|Type of Benefit (check one): |
|? Pension ? Annuity ? Retirement |
|? Other (please list): _____________________________________________________________ |
I certify that this information is accurate.
Signature Name (print)
Title Date
Agency Telephone Number
Address City State Zip
WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful, false
statements of misrepresentation to any department or agency of the U.S. or to any matter within its jurisdiction.
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