MARIF ELIGIBILITY VERIFICATION
TO: 							 RE:
										
Name

													
Social Security Number	
FROM:
							Thank you for your prompt response.  All information is confidential.
							Please contact 					 
							at (        ) 				 if you have any questions.

PERMISSION FOR RELEASE OF INFORMATION
You do not have to sign this form if either the requesting organization or the organization supplying the information 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

Date of application for housing: 			

THIS SECTION TO BE COMPLETED BY SOCIAL SERVICE AGENCY	
In accordance with the Minnesota Families Affordable Rental Investment Fund (MARIF) Program, the owner of the above development is required to have the following written statement on file from the social service agency:
	
Is the tenant listed above a current MFIP participant? 		Yes    No
If no, is the tenant listed above a recent MFIP participant? 		Yes    No
Recent MFIP participant is defined by the MARIF program as a family who left MFIP for reasons other than disqualification from MFIP due to fraud no more than twenty-four (24) months from the date of application for housing (date of application listed above).	
Date MFIP ended:  					

                                      Social Service Agency	
Signature:		Date:		
Print your name:		Tel. #:		
Title:				
Agency Name:				
Address:				

PENALTIES FOR MISUSING THIS CONTENT:  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 and any owner (or any employee of HUD 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 willingly 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 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 208 (a) (6), (7) and (8).  Violations of these provisions are cited as violations of 42 USC 408 (a), (6), (7) and (8).