CHILD/ALIMONY SUPPORT VERIFICATION

Date:

Name: MCCSEA	AMP Name:

Address: 14 West Fourth Street Dayton, Ohio 45401	AMP Address:

Phone: 937-225-4600/Fax: 937-496-7461	AMP Phone:

E-Mail Address: montg-housing-verifications@jfs.ohio.gov	E-Mail Address:

Tenant Name:	Project/Unit#:

SSN:	Applicant #:

Release: I hereby authorize the release of the requested information. Information obtained under this consent is limited to information that is no older than 12 months. There are circumstances that would require the PHA to verify information that is up to 5 years old, which would be authorized by me on a separate consent attached to a copy of this consent.

____________________________________________________	___________________________________________________

Signature of Claimant	Date

We are required to verify the incomes of all family members living in or applying for public housing or Section housing. We ask your cooperation by supplying the information requested below about the referenced person. We will use any information you provide only to determine the family’s eligibility and rent, and pledge to keep the data in strict confidence.

Information Requested:

This is a request for a record of child support payments made through the Child Support Enforcement Agency in the case referenced below:

Recipient’s Name:

State:	County:

Case#:	Account#

Currently there is no court order directing payments through this office.

There is a court order. However, there has been no record of payments received, or disbursed through this office to date.

There is a court order through this office. Payments are directed to this office and disbursed. (If checked, please attach a copy of payment record for past 12 months.) Amount of court ordered payment	per	.

Has there been any effort, by Custodian, to pursue enforcement of payments?	Yes	No

If yes, date of most recent effort:

CERTIFICATION: This form should be completed in its entirety and signed by a bona fide representative of your organization. In NO event should it be completed by the custodian or non-custodial parent.

Penalties for misusing this content: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any PHA (or any employee of HUD or the PHA) may be subject to penalties for unauthorized disclosures or improper use 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 an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD or the PHA responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 208(a), (6),(7) and (8).Violation of these provisions are cited as violations of 42 U.S.C.408 (a), (6), (7) and (8).

Name/Title of Person Supplying Information Signature	Phone# Fax#	E-mail	_________________ DATE