Download Invest Ver - Virginia Housing Development Authority

ANNUITY VERIFICATION
Date:
Project Name:
Telephone:
Fax:
Project Address:
Address 2:
TTD/TTY:
(Please return this form to the above address)
TO:
Name
Address:
City/State/Zip
RE: Tenant /
Applicant Name:
Address:
City/State/Zip:
SSN:
Unit #:
HOUSEHOLD MEMBER RELEASE
TO THE HOUSEHOLD MEMBER:
YOU DO NOT HAVE TO SIGN THIS FORM IF THE NAME OR ADDRESS OF EITHER THE PROJECT OR INVESTMENT
COMPANY IS LEFT BLANK.
RELEASE: I hereby authorize the 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 require 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.
Signature ____________________________________________________________ Date _____________________________
We are required to verify the income and assets of all individuals applying for admission as residents to
the federally aided housing units which we operate and to re-examine periodically the resident’s income.
To comply with this requirement, we ask you cooperation in supplying the following income information for
the person listed on our form. This information will be used only in determining the eligibility status and
rent of the individual, under the U.S. Department of Housing & Urban Development (HUD) Section 8
Rental Assistance Program. Your prompt return of the following information will be appreciated. If you
have any questions, please call me at
.
Signed __________________________________ (Project Representative)
Please Complete Each Item
Name(s) of Annuity Owners
What is the total contribution to the annuity?
How much is the annuity worth today?
Can it be converted to cash?
What is the cash value of the account (after
penalties, taxes and fees)?
Is the annuity earning interest at a fixed rate or a
variable rate?
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annuityform.doc
ANNUITY VERIFICATION
At what rate is the annuity earning interest?
Is this interest rate expected to increase or
decrease in the next 12 months?
Is the interest income accessible to the holder?
How much is the annuity expected to grow in the
next 12 months?
Has the owner started receiving annuity
payments?
What are the periodic payments?
How often are the payments made
(monthly/quarterly/annually)?
What is the total amount distributed to date?
I certify that the above information is true and correct.
______________________________________________
Signature of Company Official
________________________________
Title of Company Official
______________________________________________
Date Prepared
________________________________
Phone Number
This project does not discriminate against any person on the basis of race, color, religion, sex, handicap, familial status,
national origin or marital status in the admission or access to, or treatment or employment in, its federally assisted
programs and activities.
PENALTIES FOR MISUSING THIS VERIFICATION FORM
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 any 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 willfully 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.C. 208 (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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annuityform.doc