In order to properly qualify an applicant for S.H.I.P. Assistance, the following asset information for all occupants including minors must be obtained. This information will be used for qualification purposes only.

Assets Include:

Cash held in savings and/or checking accounts, trust funds, equity in real estate and other capital investments, stocks, bonds, Treasury bills, certificates of deposit, money market funds, IRA accounts, retirement and pension funds, lump sum receipts (i.e. lottery winnings, insurance settlements, etc.), and personal property held as an investment (i.e. gem or coin collections, paints, antique cars, etc.).

(Do not include necessary personal property such as furniture, automobiles, and clothing.)

I/We __________________________, the undersigned, hereby authorize City/ County/ State/ Federal/ Private Agency to release without liability, information regarding my/our employment, income, and/or assets to Jackson County Grants Section for purposes of verifying information provided as part of the owner's assistance under the SHIP program.

INFORMATION COVERED

GROUPS OR INDIVIDUALS THAT MAY BE ASKED

CONDITIONS

I/We agree that a photocopy of this authorization may be used for the purposes stated above. The original of this authorization is on file and will stay in effect for a year and one month from the date signed. I/We understand I/we have right to review this file and correct any information that I/we can provide is incorrect.

SIGNATURES

NOTE: THIS GENERAL CONSENT MAY NOT BE USED TO REQUEST A COPY OF A TAX RETURN. IF A COPY OF A TAX RETURN IS NEEDED, IRS FORM 4506 "REQUEST FOR COPY OF TAX FORM" MUST BE PREPARED AND SIGNED SEPARATELY.

Household Composition: List the head of your household and all members who live in your home. Give the relationship of each person to the head of household and their monthly income.

APPLICANT INFORMATION
APPLICANT NAME: _______________________ SS# ______________
CO-APPLICANT'S NAME: _______________________ SS# ______________
STREET ADDRESS: ________________________ PHONE: ______________
CITY: _______________________ STATE: _______ ZIP: ________
MAILING ADDRESS: ____________________________________________
CITY: _______________________ STATE: _______ ZIP: ________

INCOME INFORMATION:

Applicants' Employer:

Please complete the following for ALL members of the household:

Assets:

TYPE	CASH VALUE	ANNUAL INCOME FROM ASSETS	BANK NAME	ACCOUNT NO.
Checking Accounts:
Savings Accounts:
Credit Union Accounts:
Stocks, Life Insurance:
Other Property:
Mortgage Balance:

Liabilities (List debts including auto loans, credit cards, charge accounts, real estate & mortgage loans, etc.)

TYPE	CREDITOR'S NAME	MONTHLY PAYMENT	BALANCE
Mortgage
Rent/Lease Payment

1. Do you have any outstanding unpaid collections or judgements? Yes Amount $_____ No
2. Have you declared bankruptcy in the last 7 years? Yes No
3. Are you a party in a law suit? Yes No

The information provided above is true and complete to the best of my/our knowledge and belief. I/We consent to the disclosure of such information of purposes of income verification related to my/our application for financial assistance. I/We understand that any willful misstatement of material fact will be grounds for disqualification. Applicant understands that the information provided is needed to determine assistance eligibility and in no way assures qualification for assistance. The applicant also agrees to provide other documentation needed to verify eligibility.

SUMMARY OF FAMILY INCOME DATA

ASSETS:

ANTICIPATED ANNUAL INCOME:

***Attach Copies of the last two payroll check stubs and income tax return.***