Bank Verification Form With Permission For Release Of Information

Bank Verification

TO:

RE:

Name

Social Security Number

FROM:

Thank you for your prompt response. All information is confidential.

Please contact

at (

)

if you have any questions

PERMISSION FOR RELEASE OF INFORMATION

You do not have to sign this form if either the requesting organization or the organization supplying the information is left blank.

Release: I hereby authorize the release of the requested information. Information obtained under this consent is limited to information that is no older

than 12 months. There are circumstances which would require the owner to verify information that is up to 5 years old, which would be authorized by me

on a separate consent, attached to a copy of this consent.

Signature

Date

THIS SECTION TO BE COMPLETED BY FINANCIAL INSTITUTION

Please provide information for all accounts.

SAVINGS ACCOUNT:

Acct #:

Acct #

Current Balance

Current % Rate

Is this a joint account?

___ No / ___ No but is POD

Is this a joint account?

___ No / ___ No but is POD

___ Yes, held jointly with

CHECKING ACCOUNT:

Average Balance for the Past Six Months:

Rate of Interest:

Is this a joint account? ___ No / ___ No but is POD / ___ Yes, held jointly with

List all other asset accounts below (Certificates of Deposit, Money Market Funds, Trust, IRA's, etc.)

Account Number

Balance

Type of Account

Rate of Interest

Cash Value*

Are any of these accounts held jointly? ___ No / ___ No but is/are POD

___ Yes,

(identify which account(s)) is/are held jointly with

* CASH VALUE IS THE BALANCE MINUS ANY PENALTIES FOR EARLY WITHDRAWAL.

Signature:

Date:

Print your name:

Tel. #:

Title:

Email:

Bank Name

Address

PENALTIES FOR MISUSING THIS CONTENT: 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. HUD and any owner (or any employee of HUD or

the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the

information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willingly requests, obtains,

or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than

$5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages and seek other relief, as may be

appropriate, against the officer or employee of HUD or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for

misusing the social security number are contained in the Social Security act at 208 (a) (6), (7) and (8). Violations of these provisions are cited as

violations of 42 USC 408 (a), (6), (7) and (8).

Bank Verification

MHFA 1/16