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Y ti=t <br /> VERIFICATION OF : Assets on Deposits Name of Financial Institution <br /> ( Co-Applicant Information ) Checking Account Number <br /> Average Balance for Last 6 months <br /> Name of Applicant : <br /> Current Interest Rate <br /> Savin s Account Number <br /> Social Security Current Balance <br /> Number : <br /> Current Interest Rate <br /> Return to : <br /> Certificate of Deposit Account Number <br /> NSP Program Coordinator <br /> Indian River Habitat for Humanity Amount <br /> 4568 N . US Highway 1 Withdrawal Penalty <br /> Vero Beach , FL 32967 . <br /> Current Interest Rate <br /> Fax 772IRA , Keogh, Retirement Accounts <br /> Account Number <br /> Amount <br /> Withdrawal Penalty <br /> Current Interest Rate <br /> Your prompt return of the requested information Money Market Funds Amount (Avg . 6 month balance) <br /> will be appreciated . A self-addressed return <br /> envelope is enclosed. Interest Rate <br /> RELEASE : I hereby authorize the release Signature of or <br /> of the requested information . <br /> Authorized Representative <br /> X <br /> ( Signature of Applicant/Tenant) Agency Name : <br /> Date : Title : <br /> or ; Date : <br /> A copy of the executed " Release of Telephone : <br /> Information Form " is attached which <br /> authorizes the release of information <br /> requested . <br /> WARNING : Florida Statute 817 provides that willful false statements or misrepresentation concerning income and assets or <br /> liabilities relating to financial condition is a misdemeanor of the first degree and is punishable by fines and imprisonment provided <br /> under S 775 . 082 or 775 . 83 . <br />