401k Asset Verification Form
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1401K ASSET VERIFICATION
THIS SECTION TO BE COMPLETED BY MANAGEMENT AND SIGNED BY RESIDENT
This form must be mailed or faxed to the resident/applicant’s 401K Administrator by on-site
personnel. The resident/applicant cannot “hand carry” this form.
st
1
Request
TO: (Name & address of 401K administrator)
nd
2
Request
3rd Request
Fax #:
Attn:
RE:
Applicant/Resident Name
Social Security Number
Unit # (if assigned)
I hereby authorize release of my asset information.
Signature of Applicant/Resident
Date
The individual named above is an applicant/resident of a housing program that requires verification of assets. The information provided will remain
confidential to satisfaction of that stated purpose only. Your prompt response is crucial and greatly appreciated.
Return Form To:
Management Agent
Phone Number
THIS SECTION TO BE COMPLETED BY 401K ADMINISTRATOR
Please do not use correction
fluid.
Does the employee have access to any of the funds while employed?
_____ Yes
_____ No
If no, please sign and date the bottom of this form and return.
If yes, what amount is available for withdrawal?
$ _________________
Include only the amount available for withdrawal. Do not include
amounts that an employee can take a loan against, but must be repaid.
If this amount is zero, please sign and date the bottom of this form and return.
What is the current market value of the account?
$ _________________
What is the penalty for withdrawal?
$ _________________
What are the annual dividends or the current annual yield?
$ __________
or _________ %
Signature of 401K Administrator
Printed Name and Title
Date
Company Name
E-mail Address
Phone #
Fax #
NOTE: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the United
States as to any matter within its jurisdiction.
Quadel 10/2015
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