Housing Trust Fund
Rental Assistance Program
Employment Verification	

Name	     	
Social Security Number	     	

Permission for Release of Information

I, ____________________________________, authorize you to furnish the information requested below to:

	
	
(a stamped/addressed envelope has been enclosed)

for the purpose of determining my eligibility for participation in the Housing Trust Fund Rental Assistance sponsored by the Minnesota Housing. I understand that the information is confidential and will be used only in determining program eligibility and that I have the right to rescind this authorization in writing, at any time, but that to do so may affect my eligibility for program participation.

	Signature	
		
	Date	

Thank you for your cooperation. If you have any questions, please contact:

	at        		

Date of Employment	     	Occupation	     	 Full Time  
 Part Time	
Average Hours Worked Per:	     	     	or	     	
	Day	Week		Month	
Average Hours of Overtime:	     	     	or	     	
	Day	Week		Month	
Average Anticipated Tips Per:	     	     	or	     	
	Day	Week		Month	
Hourly rate	$     	Overtime	$      (hour)	
Medical deductions per (week/month)	$     	Effective date of last pay increase	     	
Is there a probability of a pay increase in the next 12 months?	 Yes
 No	If yes $     /hour	Date      	

		
	Print Your Name	
		
Date	Signature	
		
Telephone	Title	
		
	Firm Name	

	Firm Address