The individual named directly below is an applicant/tenant of a housing program that requires verification of income. The information
provided will remain confidential and used only to determine eligibility for housing. Please complete the section below and return it in
the enclosed self-addressed envelope. Thank you for your prompt response.
RINTED NAME OF EMPLOYEE
I hereby authorize the above named management agent to make inquiries regarding release of employment information for the purpose
of determining my eligibility for occupancy.
THE FOLLOWING TO BE COMPLETED BY
(Please provide information for all fields)
Rate of Pay: $_______________
Is Rate: hourly, weekly, bi-weekly, semi-monthly, monthly, annually?
Average number of hours worked per week: __________
Average number of months worked per year, if less than 12:________
Is an increase in pay/wage expected within the next 12 months?
If yes, please indicate effective date and amount of the increase: ________________________________
Does employee receive other forms of compensation? Yes
If yes, please indicate type and frequency below.
Overtime: Average Amount $____________ weekly, monthly, annually (Circle one)
Tips: Average Amount $_____________ weekly, monthly, annually (Circle one)
Bonuses: Average Amount $____________ weekly, monthly, annually (Circle one)
Commission: Average Amount $_____________ weekly, monthly, annually (Circle one)
Shift differential/Other Compensation: Average Amount $_____________ weekly, monthly, annually (Circle one)
Current year to date earnings
Number of pay periods included in
the YTD earnings below:
I certify that the above information is true and correct to the best of my knowledge.
WARNING: Section 1001 of Title 18 U.S. code makes it a criminal offense to make willful, false statements or
misrepresentation of any material fact involving the use of or to obtain federal funds.