Verification Of Veterans Benefits 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
Veterans Administration
Date ______________
1240 East Ninth Street
Cleveland, Ohio 44199
Fax #: 216-522-7049
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: ________________________
Date of initial award:__________ Effective date of current benefit amount:__________ Gross monthly rate $__________
This amount will increase to $__________ Effective date of the increase:__________
Current monthly deductions for medical expenses $__________
These monthly medical expenses will increase to $__________ Effective date of the increase:__________
I certify that the above information is true and correct:
Name of Representative:__________________________________________________________________ Date:________________
Name of pension fund:_________________________________________________________________________________________
Signature:_________________________________________ Title: ______________________________ Phone #: ______________
Address __________________________________________________ City ___________________ State ______ Zip ___________
Telephone ________________ Fax Number ___________________ Email ______________________________________________
You can Fax information to GMHA by using the Fax Number in the Lettehead:
Please Place VA 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.”
s8.VA Benefit Release 08282013
Online Forms


00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal