Housing Trust Fund
Rental Assistance Program
Asset 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 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        		

Savings Account	Savings Account	
Acct #	     	Acct. #	     	
Current Balance 	$      	Current Balance 	$      	
Current % Rate	     %	Current % Rate	     %	
Checking Account	
Average Balance for the Past Six Months	$      	
Rate of Interest	     %	Current Balance	$      	

Please list other asset accounts below (Certificates of Deposit, Money Market Funds, Trust, IRA's, etc.):

Account Number	Balance	Type of Account	Rate of Interest	Cash Value*	
     	$      	     	     %	$      	
     	$      	     	     %	$      	
     	$      	     	     %	$      	
     	$      	     	     %	$      	
Note: Cash value is the current value minus penalties for early withdrawal.

		
	Bank Name	
		
Print Your Name	Signature	
		
Telephone Number	Date