Chapter One – Overview
Verification of Social Security Benefits
| |Social Security Data | |
| |__________ |Date of birth | |
| |__________ |Gross monthly Social Security | |
| | |Benefit amount, type of benefit | |
|AUTHORIZATION: Federal Regulations |__________ |Gross monthly Supplemental | |
|require us to verify Social Security Benefit | | | |
| | |Security Income payment | |
|Income of all members of the household | | | |
| | |amount (including state | |
|applying for participation in the HOME | | | |
| | |supplement), type of benefit | |
|Program which we operate and to re-examine | | | |
| | | | |
|this income periodically. We ask your | | | |
|cooperation in supplying this information. This | | | |
|information will be used only to determine the | | | |
|eligibility status and level of benefit of the | | | |
|household. | | | |
|Your prompt return of the requested | | | |
|information will be appreciated. A self- | | | |
|addressed return envelope is enclosed. | | | |
| | | |
|RELEASE: I hereby authorize the release of |Signature of ________________________ or | |
|the requested information. |Authorized Representative _______________ | |
|_____________________________________ |Title: ________________________________ | |
|(Signature of Applicant) | | |
| | | | |
|Date: ________________________________ |Date: ________________________________ | |
| |Telephone: ___________________________ | |
|Or a copy of the executed “HOME Program | | |
| | | | |
|Eligibility Release Form,” 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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|[pic] |State HCD |
| |Division of Financial Assistance |
| | |
|City/County of ______________________ |
|Contact:_____________________________ |
| __________________________________ |
| |
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