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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? Page 1 of 2 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. Page 2 of 2 annuityform.doc