Verification Of Veterans Benefits Form printable pdf download

Greene Metropolitan Housing Authority

538 N. Detroit Street, Xenia, OH 45385

Xenia: 937.376.2908 Fairborn: 937.429.7736 Section 8 Fax: 937.376.2487 TDD: 937.374.1607

website: gmha.net

VERIFICATION OF VETERANS BENEFITS

Veterans Administration

Date ______________

1240 East Ninth Street

Cleveland, Ohio 44199

Fax #: 216-522-7049

Head of Household Name: __________________________________________________________ SSN # ___________________

Name of Recipient (if different) _______________________________________________________ SSN # ___________________

RELEASE: I hereby authorize the release of the requested information to Greene Metropolitan Housing Authority. Information under this consent in

limited to information that is no older than 15 months. There are circumstances that would require the owner to verify information that is up to 5 years

old, which would be addressed on a separate consent, attached to a copy of this consent. A faxed copy of this Release shall be considered an original

form and provide such authorization as stated above. I, undersigned, hereby authorize the release of the information requested below.

Signature: _________________________________________________________________________________________ Date: ________________________

SECTION BELOW IS TO BE COMPLETED BY A VA OFFICIAL

Date of initial award:__________ Effective date of current benefit amount:__________ Gross monthly rate $__________

This amount will increase to $__________ Effective date of the increase:__________

Current monthly deductions for medical expenses $__________

These monthly medical expenses will increase to $__________ Effective date of the increase:__________

I certify that the above information is true and correct:

Name of Representative:__________________________________________________________________ Date:________________

Name of pension fund:_________________________________________________________________________________________

Signature:_________________________________________ Title: ______________________________ Phone #: ______________

Address __________________________________________________ City ___________________ State ______ Zip ___________

Telephone ________________ Fax Number ___________________ Email ______________________________________________

You can Fax information to GMHA by using the Fax Number in the Lettehead:

Please Place VA Stamp Here

Warning: “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, the PHA and any owner (or 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. 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, 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 42 U.S.C208 (f)(g)

and (h). Violation of these provisions are cited as violations of 42 U.S.C. 408 f, g and h.”

s8.VA Benefit Release 08282013

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