AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION Property Name: Unit: unit: As 3 condition of participating in an affordable housing program, | understand the property owner is required to initaly and annually certify each residents elgibilty for such program, Consequently, | understand It is necessary for me to give authorization for specific income and asset information to be provided on one or more of the following forms: Employment Verification Social Securty’Supplemental Security Income Benefits Verification Public Assistance Veriication Unemployment Benefits Verification Miltary Pay Verification Pension Verification ‘Annuity of Stock Verification Deposit Verification Request ‘Student Status Verification Child Support vertication (to be used if property management has their own form) vyvyvyyery This Authorization is limited to the forms listed above and expires 180 days after the date of my signature below unless revoked in writing by me earlier. By my signature below, | authorize the representative individuals to disclose my specific income and asset information as requested on the forms abave. No other information may be released without my express writen auttrtzation Notice to aj it: Do sgt sign thig document unless the authorized management agent's signature appoars at th of this Tathikte. Dagon 1-10-22. Sinaie ol Appicanifesion Pen Name of AspsniResdent Dae By the signature of its authorized management agent below, and in consideration for execution of this ‘Authorization by the applicanUresident, property representative warrants the following: 1. Information requested on the above form is required and necessary to complete certification of the applicantiresident's eligibility to reside in the above housing property, 2. The information requested above will be used for no purpose other than determining such applicantiesident's eligibility; will be maintained as confidential personal information subject to disclosure only as required by proper administrative or judicial process, and will not be otherwise disclosed by the property owner or management; and 3. The properly owner and management have instituted procedures that insure all personally identifiable: information provided pursuant to this authorization will be maintained as (a) confidential personal information, (b) separate from that of other residents, and (c) using such physical and other security ‘measures, including security measures for protection of records maintained in electronic or magnetic ‘gfm, sufficient to protect such information from any unauthorized use, access, or disclosure. fre of Nahorized Management Agert Pint name oF Agent fe-orgimanagoratorms-RC him fo Release Confdertial formation |Rev. December 2011EMPLOYMENT VERIFICATION ‘THIS SECTION TO BE COMPLETED BY MANAGEMEN SiG ‘This form must be mailed or faxed to the resident's. ‘by onsite = ‘The resident cannot “bad cary" ths frm to Neher opens ne TO: (Name & address of employer) A request \\UA>} O BU HN etter | eee es aus 512 SE Tee 1D ‘Return Form Tor Creston Point Apartments ‘Management Agent 13445 MLK Jr. Way S. Seattle WA, 98178 (208) 772-9292 rox zosreeer Phone Number Phone: [ THIS SECTION TO BE COMPLETED BY EMPLOYER —] ‘m= Presse use GROSS amounts and dono ave any sects blank; eter oro“ or WAP OE Employee Name: Tanita Dixon vob Tite: _ Dever Presenty Emplayed: fl Yee Detar emeloyed: oo ie] 22 C) No Last DatoctEmoloment __ nif Current Gross WagesiSslary: $$ __ 25" (Check one below) Average # of reqular hours per week: 40 TKnoury — Cl wooky 7 biweekly) mer Ci cemimontiy, —) yeary 1 ote Yearto-date grosseamings:$ 10,605 trom ®@/22 trough _\(/22 ot Pay Periods included in YTD ‘weheoyy ‘aay Overtime Rate: 8 z per hour ‘Average # of overtime hours per week: Shit Difererital Rate: § ran per hour ‘Average ft shift differential hours per week: iy Commissions, bonuses, tse, other: $ __ tthe (check one below) Included in Y-T-D figure above? C1 Yes] No CD houty — Ch wooky 1} bisveek’y 1] monty © samimonthy, —] yearty other. Lstany antcipatd inrese inthe employee's rte of pay witinthe net 12monta: _ fF LY _ etectve Date: OS [23 Does the employee partcinateina 401K Retirement account? 1] Yas] No Employee can access the acoount? Ch vee’ CO No {tthe employee work s seasonal or sporado, please inccate the layoff periodle): he ‘no Social Security number wes provided, did employer view picture identification? CN ‘Additional Remarks: TL recommend Tashikka por Leare tee ARTO TWlunph We Iga acer. com Employer {Company) Name Erma Addrass Phone # Fat 'NOTE: Sean 100) of To 18 oe U.S. Cote rakes t= cvinal ose ake wR eo Sami or rasvasontatosW any Dopatnark Rawat e ‘ated Sa tony maar inn fede wor whic. orgimanagersfoms-RC him Employment Verfication instruction | Rev. October 2017 -