Housing Trust Fund
Rental Assistance Program
Social Security/SSI Verification	

Name	     	
Social Security Number	     	

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 sponsored by the Minnesota Housing Finance Agency.  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:
		                    	
Name		Tel. #	

Complete as applicable: 
Gross monthly payment	$     	
Deductions for Medicare premiums	$     	
Net amount of payment	$     	
Type of Benefits	
Social Security		Supplemental Security Income (SSI)	
Retirement			Aged
(age 65 or older)		
Disability			Disability		
Widow(er)			Blind		
Child(ren)				
The above amount became affective on:	     	

We Are Unable At This Time To Verify Information Requested	
Claim still pending	     	
No record based on identifying information	     	
Other – See reverse side of form	     	
Social Security Administration

Print Name		Date	
		                    	
Signature		Tel. #	
			
Title 		email