Verification Form - Asset - Checking, Savings, Money Market

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ASSET VERIFICATION FORM
Checking, Savings, Certificate of Deposit, and Money Market Accounts
Name of Financial Organization: ____________________________________________
PLEASE RETURN FORM TO:
Address: ______________________________________________________________
SUBJECT: Verification of Information Supplied by an Applicant/Tenant for Housing Assistance
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 Financial Organization
(Please answer all questions. Answer N/A if the question doesn’t apply.)
Checking Account
Average Balance for
Account # _________ Previous Six (6) Months: $_________ Interest Rate: ______
Date Account Opened: ________ Date Account Closed: ________
Average Balance for
Account # _________ Previous Six (6) Months: $_________ Interest Rate: ______
Date Account Opened: ________ Date Account Closed: ________
Savings Account
Account # _________ Current Balance: $___________ Interest Rate: ________
Date Account Opened: ________ Date Account Closed: ________
Account # _________ Current Balance: $___________ Interest Rate: ________
Date Account Opened: ________ Date Account Closed: ________
Certificates of Deposit
Account # ________________
Current Value _________________
Rate of Interest: ____________ Cash Value* ______________
*Cash value is the current value minus penalties for early withdrawal or cost to convert to cash (broker fees, etc.)
Account # ________________
Current Value _________________
Rate of Interest: ____________ Cash Value* ______________
*Cash value is the current value minus penalties for early withdrawal or cost to convert to cash (broker fees, etc.)
Account # ________________
Current Value _________________
Rate of Interest: ____________ Cash Value* ______________
*Cash value is the current value minus penalties for early withdrawal or cost to convert to cash (broker fees, etc.)
Money Market
Account # ________________
Current Value _________________
Rate of Interest: ____________ Cash Value* ______________
*Cash value is the current value minus penalties for early withdrawal or cost to convert to cash (broker fees, etc.)
__________________________________________ ______________________________ _______________________________
Name and Title of Person Supplying the Information
Firm/Organization Name
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 required 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 the form to the address listed above. Thank You.

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