29565
Verification of Deposit
Housing Assistance Agencies
For faster processing, please complete the form on your computer before printing.
This form is for housing assistance agencies requesting consumer deposit information. Please complete the form including the
customer authorization signature and fax to the number noted below. Your completed request will be faxed to the return fax number
provided on this form.
TYPE or complete in BLACK INK. Use only CAPITAL LETTERS
Fax Requests To.............
..
....
....
..
.
..
.. .
..
. ..........................................................................................................................1-844-879-0412
c
o
mp
l
e
t
e
i
n
Online Instructions...............................................................................................................................
Balance Confirmation Services...................................................................................................................................1-540-563-7323
SECTION 1: REQUESTER INFORMATION
Company Name
Attention
Street Address
City
State
Zip
Requester Email (optional)
-
-
-
-
Requester Phone Number
Return Fax Number
SECTION 2: CUSTOMER INFORMATION
Customer One Full Name (First Middle Last)
Customer Two Full Name (First Middle Last)
Account Number(s) (Required)
-
-
Customer One Social Security Number
/
/ 2 0
Month
Day
Year
CUSTOMER AUTHORIZATION
I/We authorize and direct Wells Fargo Bank to release the following information to the above mentioned requestor on my deposit
accounts listed above or if only a Social Security Number is provided, all open depository accounts: Account Number, Account Type,
Open or Closed, Account Holder(s), Current/Closing Balance, Open/Close Date, Current Interest Rate, Previous Six Average Statement
Balances and Previous Six Months Interest Paid. In addition, CDs and IRAs will include: Term, Maturity Date, Interest Payment, Interest
Method and Penalty.
Signature of Account Holder
Signature of Account Holder
Date
Date