Verification of Child Support

To:

Date:

Re:

SSN:

The Poinsett County Housing Authority is a federally-funded agency assisting qualified families with rent subsidies. The above named person is an applicant for, or a participant in, a federally-assisted housing program operated by the Paragould Housing Authority. All income and expenses reported to the authority must be verified in writing to determine his/her eligibility and rent payment. Please complete the lower part of this form and return by mail or fax as soon as possible.

Housing Authority Representative

Phone

I do hereby authorize the release of all information requested below to the Poinsett County Housing Authority for the purpose of determining my eligibility for housing assistance.

Signature

Date

For Office of Child Support Enforcement Use Only

The Person Named Above is Receiving Benefits Through This Office:

Yes No

1. Name of Individual Paying Child Support

Amount of Child Support Currently Received($)

Choose

Weekly Monthly

Amount of Child Support Received During past 12 Months($)

Date Child Support Payments Began

Date Child Support Payments Ended or Due to End

2. Name of Individual Paying Child Support

Amount of Child Support Currently Received($)

Choose

Weekly Monthly

Amount of Child Support Received During past 12 Months($)

Date Child Support Payments Began

Date Child Support Payments Ended or Due to End

Completed By (Signature)

Phone

Title

Date

Warning! Title 18, Section 1001 of the United States Code, states that a person who knowingly and willingly makes false or fraudulent statements to any department or agency of the United States is guilty of a felony.

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Haddii aad tahay wuxuu curyaamin ama ay ku adag tahay fahamka Ingiriisi, fadlan codsato gargaarka oo aan loo hubiyo in aad waxaa la siiya helaan macno leh oo ku salaysan baahiyahaaga shaqsi.

PLEASE RETURN TO: Poinsett County Housing Authority, 1104 Elm Street, Marked Tree, AR 72365 OR

FAX TO: (870) 358-4537