Verification Of Child Care Expenses Form

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 CHILD CARE EXPENSES

Name (Print): ____________________________________________________________________ Date: _____________________

Phone Number ____________________ Email Address:________________________________________ APPL # _____________

Child Care Provider Name: ____________________________________________________________________________________

Address __________________________________________________ City ___________________ State ______ Zip ___________

Telephone ________________ Fax Number ___________________ Email Address:_______________________________________

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: ________________________

THE SECTION BELOW IS TO BE COMPLETED BY CHILD CARE PROVIDER

If you are an individual provider, this statement must be notarized.

NAME(S) of CHILDREN

WEEKLY HOURS

WEEKLY FEE

__________________________________________________

______________

$_____________

__________________________________________________

______________

$_____________

__________________________________________________

______________

$_____________

__________________________________________________

______________

$_____________

Do you provide care during school vacations/ summers/ breaks? Yes or No Weekly Hours __________

$ ______________

Breakdown of Child Care Paid by: MONTHLY or WEEKLY (Please circle one)

CLIENT $ ___________

JFS $ _____________

OTHER $ ____________

I certify that the above information is true and correct.

Signature: _______________________________________ Date: _________________ Telephone: __________________

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 Child Care Expenses 073013

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