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TO: CALIFORNIA DEPARTMENT OF SOCIAL SERVICES <br />Ladies and Gentlemen: <br />I am receiving assistance through your office. I have applied for a rental unit located in a project financed <br />under the Housing Authority of the City of Santa Ana Multifamily Housing Program for persons of very low <br />income. Every income statement of a prospective tenant must be stringently verified. In connection with <br />my application for a rental unit, I hereby authorize the Department of Social Services to release to <br />the specific information requested below: <br />Date: <br />Signature <br />Caseload Number: Name (Print): <br />Case Number: Case Worker <br />1. Number of persons included in budget: <br />2. Total monthly budget $ <br />(a) Amount of grant $ <br />(b) Other income and source: <br />Date aid last began: <br />(c) Is other income included in total budget? No Yes <br />3. Please specify type of aid: <br />(TANF, FR, Food Stamps, ANB, Medical, Etc.) <br />4. If recipient is not receiving full grant, please indicate reason: <br />Overpayment due to client's failure to report other income <br />Computation error <br />Other <br />Date when full grant will resume: <br />Date <br />Case Worker's Signature: <br />Telephone: <br />District Office: <br />Your very early response will be appreciated. <br />