Project Information Subrecipient or State Representative’s Name: Contract No. and/or WO: Applicant’s Name: Applicant’s Physical Address: City: State: Texas Zip Code: Release Acknowledgment on the Intake Application authorizes the release and/or verification of the requested information. Authorization and Verification Federal regulations require verification of employment and income of all members of any household applying to participate in the Community Development Block Grant Disaster Recovery Program. We ask your cooperation in supplying this information to the above-referenced Subrecipient or State Representative. The information you provide will be used only to determine the eligibility status and level of benefit available to the applicant household. Based on business transacted from to Gross Income: $ Signatures Under penalties of perjury, I certify that the information presented in this Affidavit is true and accurate to the best of my knowledge and belief. I further understand that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in my ineligibility to participate in Programs that will accept this Affidavit. Title 18, Section 1001 of the U.S. code states that a person is guilty of a FELONY if he/she knowingly and willfully makes false statements to any department of the United States Government. Authorized Representative’s Printed Name: Date: Authorized Representative’s Signature:
Project Information Subrecipient or State Representative’s Name: Contract No. and/or WO: Applicant’s Name: Applicant’s Physical Address: City: State: Texas Zip Code: Release Acknowledgment on the Intake Application authorizes the release and/or verification of the requested information. Authorization and Verification Federal regulations require verification of employment and income of all members of any household applying to participate in the Community Development Block Grant Disaster Recovery Program. We ask your cooperation in supplying this information to the above-referenced Subrecipient or State Representative. The information you provide will be used only to determine the eligibility status and level of benefit available to the applicant household. Based on business transacted from to Gross Income: $ Signatures Under penalties of perjury, I certify that the information presented in this Affidavit is true and accurate to the best of my knowledge and belief. I further understand that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in my ineligibility to participate in Programs that will accept this Affidavit. Title 18, Section 1001 of the U.S. code states that a person is guilty of a FELONY if he/she knowingly and willfully makes false statements to any department of the United States Government. Authorized Representative’s Printed Name: Date: Authorized Representative’s Signature:
s4-form1409verificationofincomefrombusiness.docx