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IJ-- 1U82 <br />URBAN HENNEPIN COUNTY <br />UTILITIES CONNECTION GRANT PROSRAM <br />INCOME VE R: F I CAT I O; i <br />Date: <br />Name: <br />Address: <br />City: <br />To Whom It May Concern: <br />Zip Code <br />We are required to verify the income of all applicants for an Urban Hennepin <br />County Utilities Connection Grant. The applicant listed above nas indicated <br />that he or she is receiving income from your organization. It is essential <br />that you supply the information requested below as soon as possible. <br />Sincerely, <br />Grant administrator <br />TO THE ADDRESSEE HEREIN: You are hereby authorized to furnish all information <br />requested on this inquiry. <br />Signed: Date: <br />Monthly Social Security Benefit .............. S monthly <br />Social Security Number <br />Monthly Supplemental Security Income (SSI)... S monthly <br />Employment Income (Salary) ................... S monthly <br />Pensions ..................................... S monthly <br />By. <br />Title: <br />Organization Name: <br />Please return to: <br />Phone: <br />Date: <br />