Social Security And Supplementary Security Income Verification Form

Social Security and Supplementary Security Income Verification Form

PLEASE RETURN FORM TO:

Name of Agency: ______________________________________________

Address: ____________________________________________________

Verification of Information Supplied by an Applicant for Housing Assistance

SUBJECT:

NAME ______________________________________________

_______________________________________

ADDRESS

This person has applied for housing assistance under a program of the U.S. Department of Housing and Urban Development (HUD). HUD requires the housing owner to verify all information

that is used in determining this person's eligibility or level of benefits.

We ask your cooperation in providing the following information and returning it to the person listed at the top of the page. Your prompt return of this information will help to ensure timely

processing of the application for assistance. The applicant/tenant has consented to this release of information as shown below.

Area to be completed by the Social Security Administration

Name of original annuitant: _______________________ and Social Security Number of person receiving claim:

_______________________

Indicate information needed by checking spaces below:

_____ The gross amount of the monthly social security benefit is: $____________________

The amount deducted for Medicare is: $____________

The net amount of social security check each month is: $____________________

The above amount became effective ______________________

Month

Year

Has the monthly payment been reduced for overpayment of previous benefits? _____If yes, by how much?

_______

The monthly amount of the supplemental security income payment: $________________

____ The above amount became effective __________________________________

Month

Year

*Please provide a copy of letter or list amount in the space provided.

Complete only if you are unable to verify information requested.

__________ Claim still pending.

OR

__________ No record based on identifying information.

___________________________

_____________________________________________

Name and Title of Person

Firm/Organization Supplying the Information

Supplying the Information

____________________________________

_____________________________________________

Signature

Date

______________________

Social Security Number:

__________________________________________ ____________________________

Signature

Date

_____________________________________________________________________________________

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 that 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

Note to Applicant/Tenant:

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

PENALTIES FOR MISUSING THIS CONSENT: 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 U.S.C. 408 (a) (6), (7) and (8).

Please return form to the address listed above. Thank you