Verification Of Employment Income Form


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: ________________________
WORK SCHEDULE INFORMATION: Employer’s Name: ____________________________________________________________________________________
Hourly Rate $ ___________
Effective Date ______________
Average hours worked per week _________
Date of FIRST pay this payroll year (Actual) _________________ Payroll period starts on ____________ (day)
Employee is paid:
Commission Amount Y-T-D $ ____ ___________
Overtime Pay Rate: $ ______________
Average # of overtime hours currently worked per week: ______________
Is employment:
Co-op Student
Piecework wages
Work Study
Title V Funded
Current Y-T-D gross earnings $ ______________ as of _______________
Current Y-T-D tips if not included in gross $ ____________
Last year’s W2 gross earnings $ ________________
PAY INFORMATION: (last six months gross and pay dates)
Last Month
Previous Month
Previous Month
Previous Month
Previous Month
Previous Month
List Pay Dates in Month
Gross Monthly Earnings
Who are
Check issued to: _______________________________ Present Job Title __________________________________________________________________
EMPLOYMENT Information: (Please complete all that apply)
Start date of employment ____________
No longer employed, effective ___________
Date and Amount of final pay: __________ $ ___________
Between Assignments as of _________________
Laid off on ____________
On Leave of absence since __________ Paid? $ ________ per _______
Child Support is being withheld at the amount $ ______ per pay Employee has single/ family health insurance being withheld at the amount $ _________ per pay
I certify that the above information is true and correct:
Printed Name:__________________________________________________________________________ Date:________________
Signature:_________________________________________ Title: ______________________________ Phone #: ______________
Employer’s Address ________________________________ City ___________________ State ______ Zip ___________
Telephone ________________ Fax Number ___________________ Email ______________________________________
Please Place Employer Stamp Here
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.”


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