Verification Of Regular Contributions Form printable pdf download

Greene Metropolitan Housing Authority

538 N. Detroit Street, Xenia, OH 45385

Xenia: 937.376.2908 Fairborn: 937.429.7736 Section 8 Fax: 937.376.2487 TDD: 937.374.1607

website: gmha.net

VERIFICATION OF REGULAR CONTRIBUTIONS

Head of Household Name: ___________________________________________________ SSN # ___________________

Name of Recipient (if different) ________________________________________________ SSN # ___________________

RELEASE: I hereby authorize the release of the requested information to Greene Metropolitan Housing Authority. Information under this consent in

limited to information that is no older than 15 months. There are circumstances that would require the owner to verify information that is up to 5 years

old, which would be addressed on a separate consent, attached to a copy of this consent. A faxed copy of this Release shall be considered an original

form and provide such authorization as stated above. I, undersigned, hereby authorize the release of the information requested below.

Signature: _________________________________________________________________________________________ Date: ________________________

SECTION BELOW IS TO BE COMPLETED BY PERSON PROVIDING REGULAR CONTRIBUTIONS

I contribute $_____________ per

Week, per

Month, or per

Year to the support of:

Name (Print): ________________________________________________________________________________________________

Address __________________________________________________ City ___________________ State ______ Zip ___________

Including amounts paid directly to the person for whom you are providing support as well as bills and other living expenses regularly

paid on the person’s behalf such as utilities, phone service, car payment, insurance, cable TV, etc.

Notes/additional information:__________________________________________________________________________________

___________________________________________________________________________________________________________

Will the financial assistance continue as long as needed by client?

Yes or

No If no when will/or did it end? Date:____________

I certify that the above information is true and correct:

Printed Name:__________________________________________________________________________ Date:________________

Signature:_________________________________________ Title: ______________________________ Phone #: _____________

Address:___________________________________________________ City:__________________ State:______ Zip:___________

Relationship:_________________________________________________________ Email:_________________________________

Please Place Notary Stamp and Signature

Warning: “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, the PHA and any owner (or employee of HUD, the PHA 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, the PHA 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 42 U.S.C208 (f)(g)

and (h). Violation of these provisions are cited as violations of 42 U.S.C. 408 f, g and h.”

GMHA Verification of Regular Contributions 08072013

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