Verification Of Rent

Verification of Rent

(MMR-CC)

TO:

From:

Foxfire at Valley Lakes

2121 Kyra Drive

Lafayette, IN 47909

Ph. (765)447.2121

Fax (765)447.8787

Name of Lessee:_______________________ Address Provided:_________________________

I hereby authorize release of the requested information. Information obtained under this consent is limited to information that is no older than 12

months. There are circumstances which would required the owner to verify information that is up to 5 years old, which would be authorized by me on

a separate consent attached to a copy of this consent.

Applicant/Resident Signature

Date

Social Security Number

Information Being Requested

Address of apartment/house rented:

Move-in Date:

Move-out Date:

Amount of Rent:

Number of late payments:

Number of NSF:

Is the account satisfactory:

Yes

No

If no, how much does this person owe your property and what is

the amount for?______________________________________

Housekeeping:

Excellent

Good

Poor

If Poor, please explain:

Any lease violations:

Yes

No

If yes, explain:

Any disturbances?

Yes

No

If yes, explain:

Any damage to the property? _____ Yes _____ No

If yes, explain:______________________________________________________________________

Would you rent to this person again?

Yes

No

If no, please explain:

PENALTIES FOR SUBMITTING FALSE INFORMATION – “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 and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use

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 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 208 (a) (6), (7) and (8). Violation of

these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).**

Name and Title of Person Supplying this information

Firm / Organization

Signature

Date

Sent via:

Fax

US Postal Service

Other