HB-1-3550 

APPENDIX 8 

VERIFICATIONS 

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Appendix 8, Page 1 of 11 

(01-23-03) SPECIAL PN 

Renumbered (03-15-19) PN 522 

VERIFICATION OF PENSIONS AND ANNUITIES

REQUEST FOR INFORMATION

Federal regulations require us to verify financial information provided by applicants for housing assistance. We 

ask your cooperation in supplying the information requested. The attached Form RD 3550-1, Authorization to 

Release Information, provides the applicant's authorization. 

Your prompt return of the requested information will be appreciated. A self-addressed return envelope is enclosed 

for your convenience. If you have questions, please call ________________ at ____________________. 

APPLICANT IDENTIFICATION

Name ________________________ SSN (last 4 digits): XXX-XX-________ DOB: ____________ 

REQUESTED INFORMATION

A. INCOME FROM ANNUITIES

1. $ ____________ Current monthly gross amount received. Will the applicant continue to receive this 

monthly amount for the next twelve months? ___ Yes ___ No (If “No”, please explain.) 

2. Describe any deductions from the gross amount that are taken. 

B. VERIFICATION OF ASSETS

1. $_____________ Current market value of assets held in the retirement or pension plan. 

2. Can the applicant withdraw amounts from the retirement account without retiring or terminating employment? 

_____ Yes ______ No. If yes, explain the terms of the withdrawal, including any penalties. 

3. Can the applicant borrow against amounts in the retirement account? ___ Yes ____ No 

If yes, explain the terms (maximum amount, interest rate, repayment term, purposes, etc.). 

VERIFIER INFORMATION: Please sign this verification form and print the name, address and telephone 

number of the verifier. 

Name:________________________________ Title:______________________________________ 

______________________________________ Telephone Number:____________________ 

(Signature) 

WARNING: Knowingly and willingly making a false or fraudulent statement to any department of the United 

States Government is a felony punishable by fine and imprisonment (Title 18, Section 1001, U.S. Code) 
HB-1-3550 

VERIFICATION OF STUDENT INCOME AND EXPENSES

REQUEST FOR INFORMATION

Federal regulations require us to verify financial information provided by applicants for housing assistance. We ask 

your cooperation in supplying the information requested. The attached Form RD 3550-1, Authorization to Release 

Information, provides the applicant's authorization. 

Your prompt return of the requested information will be appreciated. A self-addressed return envelope is enclosed 

for your convenience. If you have questions, please call ________________ at ____________________. 

APPLICANT IDENTIFICATION

Name ____________________________ SSN (last 4 digits): XXX-XX-________ DOB: ____________ 

REQUESTED INFORMATION

1. Describe any financial assistance the above-referenced student receives. 

Source Amount Purpose for Which Funds May Be Used 

 

 Scholarship(s) 

 Grant(s) 

 Loan(s) 

 Work-Study 

 Other 

2. Describe any expenses the above-referenced student has for: 

 $___________ Tuition 

 $___________ Housing 

 $___________ Books 

 $___________ Supplies and Equipment 

 $___________ Transportation 

 $___________ Misc. Personal Expenses 

 $___________ Total 

VERIFIER INFORMATION: Please sign this verification form and print the name, address and telephone 

number of the verifier. 

Name:___________________________ Title:_______________________________________ 

________________________________ Telephone Number:___________________________ 

(Signature) 

WARNING: Knowingly and willingly making a false or fraudulent statement to any department of the United 

States Government is a felony punishable by fine and imprisonment (Title 18, Section 1001, U.S. Code) 

____________________________________________________________________________________

Appendix 8, Page 2 of 11 
HB-1-3550 

VERIFICATION OF MEDICAL EXPENSES

REQUEST FOR INFORMATION

Federal regulations require us to verify financial information provided by applicants for housing assistance. We ask 

your cooperation in supplying the information requested. The attached Form RD 3550-1, Authorization to Release 

Information, provides the applicant's authorization. 

Your prompt return of the requested information will be appreciated. A self-addressed return envelope is enclosed 

for your convenience. If you have questions, please call ________________ at ____________________. 

APPLICANT IDENTIFICATION

Name ___________________________ SSN (last 4 digits): XXX-XX-________ DOB:___________ 

REQUESTED INFORMATION

1. Please list the purpose of any accumulated medical bills, identify to whom the amount is owed, and provide the 

amount to be paid during the coming 12 months. 

Amount Owed To Medical Expenses for (general purpose)

2. Medical Insurance Premiums 

 $_____________ Amount Paid Payment Period: __ per month, ___ per year 

 Medical Insurance Premiums 

 $_____________ Amount Paid Payment period: __ per month, ___ per year 

3. List other anticipated medical expenses: 

VERIFIER INFORMATION: Please sign this verification form and print the name, address and telephone 

number of the verifier. 

Name:________________________________ Title:_______________________________________ 

______________________________________ Telephone Number:___________________________ 

(Signature) 

WARNING: Knowingly and willingly making a false or fraudulent statement to any department of the United 

States Government is a felony punishable by fine and imprisonment (Title 18, Section 1001, U.S. Code) 

____________________________________________________________________________________

Appendix 8, Page 3 of 11

(01-23-03) SPECIAL PN 

Renumbered (03-15-19) PN 522
HB-1-3550 

VERIFICATION OF SOCIAL SECURITY BENEFITS

REQUEST FOR INFORMATION

Federal regulations require us to verify financial information provided by applicants for housing assistance. We ask 

your cooperation in supplying the information requested. The attached Form RD 3550-1, Authorization to Release 

Information, provides the applicant's authorization. 

Your prompt return of the requested information will be appreciated. A self-addressed return envelope is enclosed 

for your convenience. If you have questions, please call ________________ at ____________________. 

APPLICANT IDENTIFICATION

Name __________________________ SSN (last 4 digits): XXX-XX-________ DOB: ____________ 

REQUESTED INFORMATION

Gross monthly Social Security benefit amount: $_____________ 

Type of benefit: ____________________________ 

Gross monthly Supplemental Security Income payment amount (including State Supplement): $______________ 

Type of benefit: ____________________________ 

Amount of monthly deductions for Medicare paid by the applicant: $_______________ 

VERIFIER INFORMATION: Please sign this verification form and print the name, address and telephone 

number of the verifier. 

Name:________________________________ Title:_______________________________________ 

______________________________________ Telephone Number:___________________________ 

(Signature) 

WARNING: Knowingly and willingly making a false or fraudulent statement to any department of the United 

States Government is a felony punishable by fine and imprisonment (Title 18, Section 1001, U.S. Code) 

____________________________________________________________________________________

Appendix 8, Page 4 of 11 
HB-1-3550 

VERIFICATION OF PUBLIC ASSISTANCE

REQUEST FOR INFORMATION

Federal regulations require us to verify financial information provided by applicants for housing assistance. We ask 

your cooperation in supplying the information requested. The attached Form RD 3550-1, Authorization to Release 

Information, provides the applicant's authorization. 

Your prompt return of the requested information will be appreciated. A self-addressed return envelope is enclosed 

for your convenience. If you have questions, please call ________________ at ____________________. 

APPLICANT IDENTIFICATION

Name _________________________ SSN (last 4 digits): XXX-XX-________ DOB: ____________ 

REQUESTED INFORMATION 

Number in family: __________ Rate Per Month 

Aid to families with dependent children $____________ 

General assistance $____________ 

Does this amount include Court Awarded Support Payments Yes No 

Amount specifically designated for shelter and utilities $_____________ 

Other assistance / type: _____________________________________ $_____________ 

Total monthly grant $_____________ 

Other income / source: ______________________________________ $_____________ 

*Maximum allowance for rent and utilities $_____________ 

Amount of public assistance given during the past 12 months $_____________ 

VERIFIER INFORMATION: Please sign this verification form and print the name, address and telephone 

number of the verifier. 

Name:________________________________ Title:_______________________________________ 

______________________________________ Telephone Number:____________________ 

(Signature) 

WARNING: Knowingly and willingly making a false or fraudulent statement to any department of the United 

States Government is a felony punishable by fine and imprisonment (Title 18, Section 1001, U.S. Code) 

____________________________________________________________________________________

Appendix 8, Page 5 of 11 

(01-23-03) SPECIAL PN 

Renumbered (03-15-19) PN 522 
HB-1-3550 

VERIFICATION OF CHILD/DEPENDENTCARE 

REQUEST FOR INFORMATION 

Federal regulations require us to verify financial information provided by applicants for housing assistance. We ask 

your cooperation in supplying the information requested. The attached Form RD 3550-1, Authorization to Release 

Information, provides the applicant's authorization. 

Your prompt return of the requested information will be appreciated. A self-addressed return envelope is enclosed 

for your convenience. If you have questions, please call ________________ at ____________________. 

APPLICANT INFORMATION CAREGIVER INFORMATION 

Name: _________________________________ Name: _________________________________ 

Address: _______________________________ Company (if applicable): ___________________ 

_______________________________________ Address: ________________________________ 

 ________________________________________ 

SERVICES PROVIDED 

The name and age of the applicant’s dependent(s) under your care: 

1. 4. 

2. 5. 

3. 6. 

_____________________________________________________________________________________________ 

Frequency and Cost of Care: 

In a typical week: 

How many hours of care do you provide the applicant’s dependent(s)? _________ 

What days do you provide care? Sun Mon Tue Wed Thurs Fri Sat 

Approximately how many weeks in a year do you provide care: ____/52 weeks 

During extended school holidays/breaks: 

How many hours of care do you provide the applicant’s dependent(s) per week? _________ 

What days do you provide care? Sun Mon Tue Wed Thurs Fri Sat 

For the services provided, the average amount charged is: $__________ per week month . 

For services to be provided during the next 12 months, the total expected cost is: $___________ for the next 12 

months. 

If any of the amount charged is paid for or reimbursed by an outside source (public services, employer, etc.), the 

amount covered by an outside source is: $__________ per week month (check the appropriate billing period). 

____________________________________________________________________________________

Appendix 8, Page 6 of 11 
HB-1-3550 

____________________________________________________________________________________

Appendix 8, Page 7 of 11

(01-23-03) SPECIAL PN 

Renumbered (03-15-19) PN 522 

VERIFICATION OF CHILD/DEPENDENTCARE – CONTINUED 

APPLICANT PAYMENT HISTORY 

Indicate the number of years you have: 

Known applicant _____ 

Provided services to applicant _____ 

What is the highest amount 

the applicant has owed you? 

$ 

How much does the applicant 

presently owe you? 

$

How would you rate the applicant’s promptness in making payments in the previous 24 months? 

 Advance On Time Late (30+ days) 

Indicate the number of times payments were late in the previous 24 months: 

30 Days 60 Days 90 Days

Use this space to include any comments you wish to make concerning your experience with the applicant’s 

payment history. 

VERIFIER INFORMATION: 

Name:_______________________________________ Date:______________________________ 

 _______________________________________ Telephone Number:___________________ 

 (Signature) 

Title: _______________________________________ 

WARNING: Knowingly and willingly making a false or fraudulent statement to any department of the United 

States Government is a felony punishable by fine and imprisonment (Title 18, Section 1001, U.S. Code). 
HB-1-3550 

VERIFICATION OF UNEMPLOYMENT BENEFITS

REQUEST FOR INFORMATION

Federal regulations require us to verify financial information provided by applicants for housing assistance. We 

ask your cooperation in supplying the information requested. The attached Form RD 3550-1, Authorization to 

Release Information, provides the applicant's authorization. 

Your prompt return of the requested information will be appreciated. A self-addressed return envelope is 

enclosed for your convenience. If you have questions, please call ________________ at ___________________. 

APPLICANT IDENTIFICATION

Name ___________________________ SSN (last 4 digits): XXX-XX-________ DOB:____________ 

REQUESTED INFORMATION

1. Are benefits being paid now? Yes No 

2. If yes, what is gross weekly payment? $________________ 

3. Date of initial payment _________________ 

4. Duration of benefits _________________ weeks 

 Is claimant eligible for future benefits? Yes No 

5. If yes, how many weeks? _________________ 

6. If no, what is termination date of benefits? __________________ 

VERIFIER INFORMATION: Please sign this verification form and print the name, address and telephone 

number of the verifier. 

Name:________________________________ Title:___________________________________ 

______________________________________ Telephone Number:____________________ 

(Signature) 

WARNING: Knowingly and willingly making a false or fraudulent statement to any department of the United 

States Government is a felony punishable by fine and imprisonment (Title 18, Section 1001, U.S. Code) 

____________________________________________________________________________________

Appendix 8, Page 8 of 11
HB-1-3550 

VERIFICATION OF BUSINESS EXPENSES

REQUEST FOR INFORMATION

Federal regulations require us to verify financial information provided by applicants for housing assistance. We 

ask your cooperation in supplying the information requested. The attached Form RD 3550-1, Authorization to 

Release Information, provides the applicant's authorization. 

Your prompt return of the requested information will be appreciated. A self-addressed return envelope is enclosed 

for your convenience. If you have questions, please call ________________ at ____________________. 

APPLICANT IDENTIFICATION

Name ___________________________ SSN (last 4 digits): XXX-XX-________ DOB: ____________ 

REQUESTED INFORMATION 

Based on business transacted from __________________ 20____, to __________________ 20____ 

1. Gross Income $________________ 

2. Expenses: 

 (a) Interest on Loans $________________ 

 (b) Cost of Goods/Materials $________________ 

 (c) Rent $________________ 

 (d) Utilities $______________________________ 

 (e) Wages/Salaries $________________ 

 (f) Employee Contributions $________________ 

 (g) Federal Withholding Tax $________________ 

 (h) State Withholding Tax $________________ 

 (i) FICA $________________ 

 (j) Sales Tax $________________ 

 (k) Other $________________ 

 (l) Straight Line Depreciation $________________ 

 Total Expenses $________________ 

3. Net Income $________________ 

VERIFIER INFORMATION: Please sign this verification form and print the name, address and telephone 

number of the verifier. 

Name:________________________________ Title:_______________________________________ 

______________________________________ Telephone Number:____________________ 

(Signature) 

WARNING: Knowingly and willingly making a false or fraudulent statement to any department of the United 

States Government is a felony punishable by fine and imprisonment (Title 18, Section 1001, U.S. Code) 

____________________________________________________________________________________

Appendix 8, Page 9 of 11 

(01-23-03) SPECIAL PN 

Renumbered (03-15-19) PN 522 
HB-1-3550 

VERIFICATION OF SUPPORT PAYMENTS

REQUEST FOR INFORMATION

Federal regulations require us to verify financial information provided by applicants for housing assistance. We 

ask your cooperation in supplying the information requested. The attached Form RD 3550-1, Authorization to 

Release Information, provides the applicant's authorization. 

Your prompt return of the requested information will be appreciated. A self-addressed return envelope is 

enclosed for your convenience. If you have questions, please call __________________ at _________________. 

APPLICANT IDENTIFICATION

Name _______________________ SSN (last 4 digits): XXX-XX-________ DOB: ____________ 

REQUESTED INFORMATION

Name of Person Paying Support: ___________________________________________ 

Address:___________________________________ __________________________________ 

Unit/Apt#:__________________________________ 

City: ______________________________________ 

State, Zip:__________________________________ 

For: ( ) Former Spouse 

 ( ) Children 

Children names are: 

1. 4. 7. 

2. 5. 8. 

3. 6. 9. 

Amount of Support: $_____________ Week Month Year 

VERIFIER INFORMATION: Please sign this verification form and print the name, address and telephone 

number of the verifier. 

Name:________________________________ Title:___________________________________ 

______________________________________ Telephone 

Number:____________________ 

(Signature) 

WARNING: Knowingly and willingly making a false or fraudulent statement to any department of the United 

States Government is a felony punishable by fine and imprisonment (Title 18, Section 1001, U.S. Code) 

____________________________________________________________________________________

Appendix 8, Page 10 of 11
HB-1-3550 

RECORD OF ORAL VERIFICATION

APPLICANT INFORMATION 

Re: _______________________________________________________________________________ 

Address: __________________________________________________________________________ 

__________________________________________________________________________________ 

Date Received: _________________________________

INFORMATION VERIFIED

Item verified: __________________________________ 

Person contacted: _______________________________ 

Representing: ___________________________________ 

INFORMATION SUPPLIED

_____________________________________ ___________________ ___________________ 

Signature of Person Receiving Verification Date Time 

WARNING: Knowingly and willingly making a false or fraudulent statement to any department of the United 

States Government is a felony punishable by fine and imprisonment (Title 18, Section 1001, U.S. Code) 

____________________________________________________________________________________

Appendix 8, Page 11 of 11 

(01-23-03) SPECIAL PN 

Renumbered (03-15-19) PN 522