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LAKESIDE CENTER INC. <br />PENSION &ANNUITY <br />Dear Sir/Madam: <br />Date <br />RE: <br />I.D. # <br />We are required to verify incomes of all members. of families applying for <br />admission as tenants to federally assisted housing units which we operate- and <br />redetermine periodically the income of the tenant families. This is because the laws <br />under which housing units are administered restrict occupancy to low-income families <br />and based on the amount of family income. <br />To comply with this requirement, we ask your cooperation in completing the <br />applicable items on the following report for the employee listed above. This information <br />will be used only in determining the eligibility status and rent of the employee's family. <br />Your prompt return of this letter will be appreciated. A self-addressed return <br />envelope is enclosed. If you have any questions, please call <br />Sincerely, <br />Manager <br />I hereby authorize the release of the requested information. <br />Date Applicant's Signature <br />Current monthly gross amount of pension or annuity $ <br />Deductions from gross for medical insurance premium $ <br />Date of initial award <br />Effective date of current award <br />Date <br />Signature <br />Title <br />We are pledged to the letter and spirit of U.S. Policy for adrievernent of equal iwusing opportunity <br />throughout the Nation. We encourage and support an aff rmadw advertising and marketing program in <br />which th= are no barriers to obtaining housing because of race, color, religion, sex,. handicap, familial <br />status or national Origin <br />DOC 217 <br />