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LAKESIDE CENTER INC. <br />SOCIAL SECURITY VERIFICATION <br />PROJECT NAME <br />ADDRESS <br />CITY, STATE, ZIP CODE <br />The Federal Government requires verification of annual incomes of applicants and <br />tenants in order to establish eligibility for low -rent housing. <br />is unable to produce a copy of his or her award <br />or disability allowance letter regarding a claim for monthly benefits under the Social <br />Security Act/. The information will be used only for the purpose stated and will not be <br />disclosed to any other organization or individual. Therefore, we would appreciate <br />information regarding benefit payments made to the below -named individual: <br />Name: <br />Social Security Number% <br />Address: <br />Authorization for the release of this information is given below. <br />I hereby authorize and request the Social Security Administration to furnish the following <br />information, which is necessary to determine (my) (our) eligibility and rent for low -rent <br />housing. <br />Date: <br />Signature: <br />INFORMATION TO BE ENTERED BY SOCIAL SECURITY ADMINISTRATION: <br />Name Monthly Payments Effective Date of Award <br />Signature: <br />We are pledged to the letter and spirit of U.S. Policy for achievement of equal housing opportunity <br />throughout the Nation. We encourage and support an affirmative advertising and marketing program in <br />which there are no barriers to obtaining housing because of race, color, religion, sex handical% familial <br />status or national origin. <br />DOC 206 <br />