Download STOCKS / BONDS VERIFICATION

STOCKS / BONDS VERIFICATION
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TO: (Name & address)
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
RE:__________________________________
_____________________
Applicant/Tenant Name
____________________
Social Security #
Unit # (if assigned)
I hereby authorize release of the requested information.
___________________________________________
____________________________
Signature of Applicant/Tenant
Date
The individual named directly above is an applicant/tenant of a housing program that requires verification of income. The
information provided will remain confidential to satisfaction of that stated purpose only. Your prompt response is crucial and
greatly appreciated.
_______________________________
Project 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 & title:________________________________ Tel. #:____________________________________
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.