Housing Trust Fund
                              Rental Assistance Program
Public Assistance Verification lic	

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 Program (HTFRA) sponsored by 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	     	

Current Address	     	
Date of Birth	     	
Does the above address match your records?	 Yes    No	
Number of Persons on Grant	      Adults         Children	

	Monthly Amount	Full Grant?	
MN Family Investment Plan - Statewide	$      	 Yes    No	
General Assistance	$      	 Yes    No	
Other Assistance Type:      	$      	 Yes    No	

Effective date of grant	     	
If this person is not receiving the full grant, please explain why:	     	
When do you anticipate the full grant will be reinstated?	     	
Other known household income? 	 Yes    No   Please describe:      
If Yes, what is the monthly amount? $      	
Does this person receive a child support pass through?	 Yes    No   
If Yes, what is the monthly amount? $      
Total amount received during the last 12 months: $      
If No, has every reasonable effort been made by the applicant to collect any amount which may be due, including, but not limited to, filing with the appropriate courts or agencies responsible for the enforcement of any payments?
 Yes    No   	

Department of Social Services

	Print Name	
		
Date	Signature	
		
Telephone Number	Title