SK-70 VERIFICATION OF GIFTS/MONETARY OR NON-CASH …

1 Request for VERIFICATION of Gifts, monetary or NON-CASH contributions SK Management Company, LLC. DATE: _____ Mail Fax DATE: _____ 2nd ATTEMPT Mail Fax Property Name Address _____ _____. Applicant/Tenant Name of Provider _____ _____. Address Address _____ _____. Phone # _____. The above-referenced family has indicated that you provide recurring contributions to their household. We are required to verify the income and gifts received by all members of all families who reside in the federally aided housing units which we operate. To comply with this requirement, we ask your cooperation in supplying the following information for the person listed above. This information will be used only in determining the eligibility status and rent of the family. Please return in the enclosed self-addressed, stamped envelope. Sincerely, Occupancy Division Signature: _____. Occupancy / Rental Specialist Applicant/Resident: You do not have to sign this form if either the requesting organization or the organization supplying this information is left blank.

2 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 owner 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. Date: _____ Signature: _____. Tenant / Applicant THIS FORM IS SUBJECT TO GOVERNMENT REVIEW AND YOUR NAME WILL BE SHOWN AS INCOME PROVIDER. THIS. FORM WILL NOT BE ACCEPTED UNLESS ALL QUESTIONS ARE ANSWERED & STATEMENT NOTARIZED. PLEASE SEE. REVERSE SIDE. I certify under the penalty of perjury that the following is true: 1. I provide monetary support to the applicant/tenant listed above Yes No If yes, please proceed to #2. If no, fill out and sign the bottom portion of the reverse side of this form. 2. monetary gift $_____ Effective date contribution began: _____.

3 How often is this gift provided? _____ weekly _____ monthly _____ yearly 3. In what form is payment made? _____ Cash _____ Money Order _____ Check How long will payments continue: _____. 4. What is your relationship to tenant/applicant? _____. 5. Do you claim this tenant/applicant as a dependent on your taxes? Yes No 6. If you no longer provide monetary support, on what date did it stop? _____. SK 70 (Rev 5/4/2016) (OVER). If you know which items below your monetary contribution is used for, please list below: Cash Contribution Expense Sheet Approx. Monthly Item Responsible Party Amount Rent Payment Rent Utilities (gas elect, etc.). Phone (including cell phone). Cable/Internet Food Tobacco products Clothing (for self and children). School supplies/uniforms Diapers Baby Formula Cleaning Supplies (dish soap, bathroom supplies, etc.). Toiletries (shampoo, deodorant, etc.). Laundromat (including laundry soap, etc.)

4 Doctor Visits Prescriptions Car Loan Gasoline Car Insurance Car Maintenance (tires, oil changes, etc.). Credit Card Payments Entertainment (includes movie/video game rental, music download apps etc.). Other Monthly Payments TOTAL MONTHLY EXPENSES. I do not know how money is spent _____ (initials). Print Name of Person Supplying Information Title of Person Supplying Information Firm/Organization: _____. Address: _____ Telephone#: _____. (please complete). Signature: _____ Date : _____. PENALTIES FOR MISUSING THIS CONSENT: Title 18, Section 1001 of the 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, the PHA, and any owner (or any employee of HUD, the PHA, or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form.

5 Use of the information collected based on this VERIFICATION form is restricted to the purposes cited above. Any person who knowingly or willfully 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, the PHA, or the owner 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). Violations of these provisions are cited as violations of 42 408 (a) (6), (7) and (8). SK 70 (Rev 5/4/2016).