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TO: SOCIAL SECURITY ADMINISTRATION <br />Ladies and Gentlemen: <br />I have applied for a rental unit located in a project financed under the Housing Authority of the City of Santa <br />Ana Multifamily Housing Program for persons of very low income. Every income statement of a prospective <br />tenant must be stringently verified. In connection with my application for a rental unit, I hereby give my <br />consent to release to the specific information requested <br />below. <br />Date: _ <br />Signature <br />Social Security No.: <br />Address (Print): <br />Name (Print): <br />Monthly Benefits Began/Will Begin: <br />Social Security Benefit Amount: $ <br />Other Benefit(s): <br />Medicare Deduction: $ <br />Are benefits expected to change? No <br />If Yes, please state date and amount <br />Date: of change: Amount: $_ <br />Yes <br />Amount: $ <br />If recipient is not receiving full benefit amount, please indicate reason and date recipient will start receiving <br />full benefit amount: <br />Reason: Date of Resumption: Amount: $ <br />Date: <br />Signature: <br />Name (Print): <br />Title: <br />Telephone: <br />Please send form to: <br />INCOME VERIFICATION <br />(for Department Social Services recipients) <br />