Stocks / Bonds Verification Form
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1STOCKS / BONDS VERIFICATION
TO:
(Name & address)
_____________________________________
_____________________________________
_____________________________________
RE: _________________________________
_________________________
_______________________
Applicant/Tenant Name
Social Security Number
Unit # (if assigned)
I hereby authorize release of the requested information.
_______________________________________
________________________________
Signature of Applicant/Tenant
Date
We are required by the Internal Revenue Service (IRS) to verify the incomes of all family members applying for admission to any Low Income
Housing Tax Credit Program housing. The Delaware State Housing Authority monitors compliance for IRS requirements. Please complete the form
below and return it to the address shown below as soon as possible. This information will only be used to determine the family's eligibility for
admission or continued occupancy. Your cooperation is appreciated.
_______________________________________
Property Owner/Management Agent
:
MAIL OR FAX THIS FORM TO
THIS SECTION TO BE COMPLETED BY BROKER OR AUTHORIZED OFFICIAL
STOCKS:
Name of Stock Company:
____________________________________________________________________________________
Current Market Value minus broker/legal fees for conversion to cash:
$___________________________________________
Total dividends paid in previous 12 months (included even if reinvested):
$___________________________________________
Name of Stock Company:
____________________________________________________________________________________
Current Market Value minus broker/legal fees for conversion to cash:
$___________________________________________
Total dividends paid in previous 12 months (included even if reinvested):
$___________________________________________
BONDS:
Name of Issuing Agent: ________________________________________________________________________________________
Current Market Value minus broker/legal fees for conversion to cash:
$___________________________________________
Total interest paid in previous 12 months:
$___________________________________________
Name of Issuing Agent: ________________________________________________________________________________________
Current Market Value minus broker/legal fees for conversion to cash:
$___________________________________________
Total interest paid in previous 12 months:
$___________________________________________
Signature of Broker or Authorized Official
Signature:
__________________________________
Date:__________________________
Print your name: __________________________________
Telephone #: __________________
Title:
__________________________________
Company Name __________________________________
Address
__________________________________
__________________________________
Warning: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any
Department or Agency of the United States as to any matter within its jurisdiction.
STOCKS/BONDS VERIFICATION 05/2005
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