MAINE STATE HOUSING AUTHORITY

Stability Through Engagement Program (STEP) 353 Water Street

Augusta, ME 04330

207-626-4600 or Fax 207-624-5768

7-1-1 (Maine Relay)

NAME: INSTITUTION:

SSN: ADDRESS:

RE: ASSET VERIFICATION

Federal Law and regulations require us to verify the sources and amounts of income of all applicants for

admission as tenants to our federally assisted housing program and to re-examine periodically the incomes of

existing tenant families. All information is confidential and will be used only in determining eligibility for

rental assistance.

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SAVINGS ACCOUNT(S) Current Balance Interest Rate Date

$________________ ____________% _________________

$________________ ____________% _________________

$________________ ____________% _________________

CHECKING ACCOUNT(S): Current Balance Interest Rate Date

$________________ ____________% _________________

$________________ ____________% _________________

Average balance for the past (six) months: $__________________ PLEASE LIST ANY OTHER ASSET ACCTS (CD’S, MONEY MARKETS, IRA’S, TRUSTS, ETC.)

Type Interest Rate Balance Cash Value

____________________ _______________% $________________ $________________

____________________ _______________% $________________ $________________ **NOTE: THE CASH VALUE IS THE CURRENT VALUE MINUS PENALTIES FOR EARLY WITHDRAWAL

__________________________________________________ _____________________________

Signature/Title Date

Phone ____________________________________

MAINE STATE HOUSING AUTHORITY

Stability Through Engagement Program (STEP) 353 Water Street

Augusta, ME 04330

207-626-4600 or Fax 624-5768

7-1-1 (Maine Relay)

Name: Institution:

SS#: Address:

SUBJECT: Assets: Stocks/Bonds/Securities

Federal law and regulations require us to verify the sources and amounts of income of all applicants for

admission as tenants to our federally assisted housing program and to re-examine periodically the incomes of

existing tenant families. All information is confidential and will be used only in determining eligibility for

rental assistance.

Number of Current Market Current Dividends Earned

Type Shares Owned Value per Share Dividend Rate Past 12 months

____________ __________ _____________ ____________ _______________

____________ __________ _____________ ____________ _______________

____________ __________ _____________ ____________ _______________

____________ __________ _____________ ____________ _______________

____________ __________ _____________ ____________ _______________

____________ __________ _____________ ____________ _______________

__________________________________________ ________________________

Signature/Title Date

__________________________________

Phone

Penalties for misusing this consent: Title 18, Section 1001 of the US Code states that a person is guilty of felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties fur unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willingly requests, obtains, or discloses any information under false pretenses concerning any applicant or participant may be subject to a misdemeanor and fined not more than $5000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages and see other relief, as may be appropriate, against the officer or employee of HUD, the PHA or the owner responsible for the unauthorized disclosure or improper use.

CERTIFICATION OF ZERO INCOME

MaineHousing STEP Program

Household Name: SSN:

Address: City:

I hereby certify that I do not individually receive income from any of the following sources: 1. Employment wages including: overtime, commissions, tips, bonuses, fees etc. 2. Unemployment compensation. 3. Income from operation of a business: sales from self-employment resources. 4. Rental income from real or personal property. 5. Interest/dividends from Assets: savings/checking accounts, annuities, insurance policies,

retirement funds, pensions or death benefits.

6. Social Security (SS) and/or Supplemental Security Income (SSI) benefits. 7. Public assistance payments including: General Assistance, TANF and/or Food Stamps. 8. Regular contributions/gifts received from person not living in the household. 9. Alimony and/or Child Support payments.

Please list the payment sources for the following expenses. If you need additional space, please use back side of this form: Monthly Expenses: Source of Funds: Address of Source:

Food. Grocery bill X 4 wks

Communications. Telephone /cell phone, internet connection.

Transportation. Bus fares. Taxi fares. Personal car expenses: gas, insurance, maintenance, or tires.

Medical. Unreimburseable .

Living. Clothing. Cleaning supplies, personal grooming and paper products.

Entertainment. magazines, memberships, etc.

Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. The undersigned further understand(s) that providing false representations herein constitutes an act of fraud. I understand that providing false, misleading or incomplete information may result in the termination of my housing assistance. ________________________ ________________________ _________________ Tenant/Applicant Signature Printed Name Date

Penalties for misusing this consent: Title 18, Section 1001 of the US Code states that a person is guilty of felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties fur unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willingly requests, obtains, or discloses any information under false pretenses concerning any applicant or participant may be subject to a misdemeanor and fined not more than $5000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages and see other relief, as may be appropriate, against the officer or employee of HUD, the PHA or the owner responsible for the unauthorized disclosure or improper use.

For additional space, please enter below: Monthly Expenses: Source of Funds: Address of Source:

Food. Grocery bill X 4 wks

Communications. Telephone /cell phone, internet connection.

Transportation. Bus fares. Taxi fares. Personal car expenses: gas, insurance, maintenance, or tires.

Medical. Unreimburseable .

Living. Clothing. Cleaning supplies, personal grooming and paper products.

Entertainment. Cable or Dish TV, magazines, club memberships, liquor/beer/wine, lottery tickets, cigarettes.

MAINE STATE HOUSING AUTHORITY

Stability Through Engagement Program (STEP) 353 Water Street

Augusta, ME 04330

207-626-4600 or Fax 207-624-5768 7-1-1 (Maine Relay)

CHILD CARE VERIFICATION

NAME PROVIDER

SSN ADDRESS

NAME(S) OF CHILD(REN) BEING CARED FOR:

_________________________________ ________________________________

__________________________________ ________________________________

__________________________________ ________________________________

HOW MANY DAYS PER WEEK? _______________ HOURS PER DAY ________________

CHARGE PER DAY _____________ PER WEEK _______________ PER HOUR__________

DO CHARGES VARY FOR ANY REASON? (example: child in school) IF YES, PLEASE

EXPLAIN. ____________________________________________________________________

______________________________________________________________________________

DO YOU RECEIVE MONEY FROM ANY OTHER PERSON OR AGENCY TOWARD THE

AMOUNT YOU CHARGE FOR THE ABOVE NAMED CHILD(REN)? IF YES, WHO?

_____________________________________________________________________________

TOTAL AMOUNT YOU RECEIVED FOR THE LAST 12 MONTHS: ____________________

_______________________________________ _________________________

Signature Dat