Income Verification Release

Date: *

Tenant/Applicant Name:*

Social Security No.: *

Tenant/Applicant Email: *

PURPOSE OF DATA COLLECTION

In order to establish eligibility for admission and continuing occupancy in public housing, Osceola Housing Authority is required by law to verify the income of all applicants prior to admission, and residents on at least an annual basis. The person identified above has informed us that he or she is now, or has within the last 12 months been employed by your firm. Your cooperation and prompt return of the requested information will allow us to meet this requirement. All information supplied will be held in strict confidence and used by Osceola Housing Authority only to the extent legally required.

CONSENT TO RELEASE INFORMATION

I, *

authorize employer *

to release the following information:

EMPLOYMENT INFORMATION

Start Date *

To: *

Full time Part-time Temporary Seasonal

Hours *

Per *

Pay rate: $ *

Per *

Est. tips: $ *

Per *

Bonus $ *

Commission $ *

Actual earnings in past 12 months or time of employment if less than 12 months:

From *

To: *

Actual overtime hours in past 12 months or time of employment if less than 12 months:

Hours *

Earnings: $ *

INFORMATION PROVIDER

Firm Name *

Date *

Completed by *

Phone No *