NON-WAGE INCOME VERIFICATION FORM
DATE: _______________
TO (PROVIDER OF NON-WAGE INCOME): ________________________________________________________
FROM (HOUSING SPECIALIST): ________________________________________________________________
RE (TENANT NAME): ________________________________________________________________________
The household member named above is applying for or recertifying eligibility for housing assistance. Housing and Urban Development (HUD) regulations require us to verify all information used in determining the household’s eligibility for housing assistance. The household member has informed us that you have been providing financial assistance to them. Please provide us with the information requested below. The household member has consented to the release of this information as shown below. Please return this form promptly to the Housing Specialist named above.
HOUSEHOLD MEMBER 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.
HOUSEHOLD MEMBER’S SIGNATURE: _________________________________ DATE: _______________
INFORMATION REQUESTED:
PERSON PROVIDING NON-WAGE INCOME: _______________________________________________________
DATE ASSISTANCE BEGAN: ____________________________________________________________________
MONTHLY AMOUNT GIVEN: ___________________________________________________________________
I, __________________________________, hereby swear all information provided is true and complete to the best of my knowledge.
SIGNATURE: ___________________________________________ DATE: ________________________
WARNING: 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.
ALTERNATIVE FORMATS OF THIS DOCUMENT ARE AVAILABLE UPON REQUEST.
575 Union Blvd Suite 100, Lakewood, Colorado 80228 ● Phone 303-987-7580 ● TTY 711 ● www.mwhs.org