Form TPVR1-16 Third Party Verification Reqest (TPVR)

U.S. DEPARTMENT OF HOUSING AND
URBAN DEVELOPMENT
c/o ICF International
Attn: HUDQC
530 Gaither Road, Suite 500
Rockville, MD 20850

To:

Boxes for Official use Only

C/P/C

TPVR-1
Periodic Payment Verification

Macro Link

Re:
ID:

Please Provide Periodic Payment Verification Information for the Person Named Above.
1.

If you have no record of the person named above, please check the box and return the form. 

2.

Please provide benefit history from [17 or 5 months prior to the QCM] through [QCM] by attaching
documents containing the following information clearly labeled:
•
•
•
•

3.

Type of payment
Gross benefit amount
Medical/other insurance
Other deductions

Were any of the benefits described above funded by any of the sources listed below?

 Yes  No

IF YES, circle which type:
01 = Payments for care of foster children/adult
02 = Student financial assistance
03 = Refunds/rebates for property taxes
04 = Disposition of funds of the Grand River band of Ottawa
Indians
05 = Shares received from judgment funds by Indian claims or
U.S. claims court
06 = Maine Indian claims act
07 = Amounts paid by a state agency to a family member who
has a developmental disability
08 = Bureau of Indian Affairs student assistance programs
09 = Child care under Child Care and Development Block Grant
Act of 1990
10 = Any amount of crime compensation under the Victims of
Crime Act
11 = LIEAP (Low Income Energy Assistance Program)
12 = Reimbursement for medical expenses

13
14
15
16
17
18

=
=
=
=
=
=

19 =
20 =
21 =
22 =
23 =
24 =
25 =

Nazi era reparation payments paid by a foreign government
Adoption assistance payments
Income from sub marginal land
Alaska Native Claims Settlement Act
Agent orange settlement
Allowances paid to a child suffering from spina bifida who is a
child of Vietnam veteran
Payments to Yakima or Apache Indians by Indian Claims
Commission
Earned income tax credit
Food stamps
Payments set aside under a Plan to Attain Self Sufficiency
(PASS)
Monetary value of groceries by person not in living in the
household
Transitional assistance subsidy
2012 Tax Rebates provided by the IRS

If you are unable to provide the requested information for the entire time period, provide as much information
during that time period as available and an explanation below.
Explanation: __________________________________________________________________________
______________________________________________________________________________________
Return the completed form in the self-addressed, stamped envelope provided by ____/___/____ OR fax the
completed form toll free to: 800-823-0127. If you have any questions, call toll free: 877-392-9776.
Name and title of person completing the form: _______________________________________________________
Signature: ___________________________ Phone Number: _____________________ Date: ____/_____/______
FY 2013 Third Party Verification Request

1

U.S. DEPARTMENT OF HOUSING AND
URBAN DEVELOPMENT

c/o ICF International
Attn: HUDQC
530 Gaither Road, Suite 500
Rockville, MD 20850

To:

TPVR-2
Asset Verification

Boxes for Official use Only

C/P/C

Macro Link

Re:
ID:

Please Provide Asset Verification Information for the Person Named Above for All Accounts Held at Your
Institution.
1.

If you have no record of the person named above, please check the box and return the form. 

2.

Please provide account history for each account held by the person named above from [17 or 5 months prior
to QCM] through [QCM] by attaching documents that contain the following information clearly labeled:
•
•
•
•
•

Average monthly value of the asset
Annual income (from interest, dividends, etc.,)
Interest rate
Cost to dispose of the asset
Name of co-owner (if jointly owned)

If you are unable to provide the requested information for the entire time period, provide as much information
during that time period as available and an explanation below.
Explanation: __________________________________________________________________________
______________________________________________________________________________________
Return the completed form in the self-addressed, stamped envelope provided by ____/___/____ OR fax the
completed form toll free to: 800-823-0127. If you have any questions, call toll free: 877-392-9776.
Name and title of person completing the form: _______________________________________________________
Signature: ___________________________ Phone Number: _____________________ Date: ____/_____/______
FY 2013 Third Party Verification Request

2

U.S. DEPARTMENT OF HOUSING AND
URBAN DEVELOPMENT

c/o ICF International
Attn: HUDQC
530 Gaither Road, Suite 500
Rockville, MD 20850

To:

Boxes for Official use Only

C/P/C

TPVR-3
Employment Income Verification

Macro Link

Re:
ID:

Please Provide Employment Information for the Person Named Above
1. If you have no record of the person named above, please check the box and return the form. 
2. Please provide employment start date and employment end date (if no longer employed):
a. Employment Start Date (MM/DD/YYYY): _ _ / _ _ / _ _ _ _
b. Employment End Date (MM/DD/YYYY): _ _ / _ _ / _ _ _ _
3. Please provide pay history from [17 or 11 months prior to the QCM] through [QCM] by attaching documents
that contain the following information clearly labeled:
•
•
•
•

Gross Pay
Over-time Pay
Bonus
Medical Insurance/Other Insurance Deductions

•
•
•
•

Tips
Commissions
Other Pay
Other Allowances

For Active Military: include all allowances including in addition to base pay. For e.g., housing allowance,
food allowance, uniform allowance.
For National Guard/Reserve: include drill pay, reserve pay and active duty pay
4. Was any of the pay described above funded by any of the sources listed below?

 Yes  No

IF YES, circle which type:
01 = Federal Work Study Program

07 = RSVP (Retired Senior Volunteer Program)

02 = AmeriCorps participants

08 = Foster Grandparents

03 = JTPA (Job Training Partnership Act)

09 = Senior Companions

04 = Workforce Investment Act of 1998

10 = Program Bureau of Indian Affairs Student Assistance Programs

05 = VISTA volunteers

11 = Resident service stipend

06 = Payments funded through the Older Americans Act, including:

17 = Agent Orange Settlement (Active Military or National
Guard/Reserve)

•
•
•
•
•
•
•
•

Green Thumb
AARP
Natl. Council on Aging (NCOA)
Natl. Council of Senior Citizens
U.S. Forest Services
Natl. Caucus of Black Aged (NCBA)
Natl. Assoc. for the Spanish Elderly
Urban League

18 = Allowances paid to a child of a Vietnam veteran who suffers
from spina bifida (Active Military or National Guard/Reserve)
26 = Hostile fire pay (Active Military or National Guard/Reserve)

If you are unable to provide the requested information for the entire time period, provide as much information
during that time period as available and an explanation below.
Explanation: __________________________________________________________________________
______________________________________________________________________________________
Return the completed form in the self-addressed, stamped envelope provided by ____/___/____ OR fax the
completed form toll free to: 800-823-0127. If you have any questions, call toll free: 877-392-9776.
Name and title of person completing the form: _______________________________________________________
Signature: ___________________________ Phone Number: _____________________ Date: ____/_____/______
FY 2013 Third Party Verification Request

3

U.S. DEPARTMENT OF HOUSING AND
URBAN DEVELOPMENT

c/o ICF International
Attn: HUDQC
530 Gaither Road, Suite 500
Rockville, MD 20850

TPVR-4
Training Program Verification

Boxes for Official use Only

C/P/C

To:

Macro Link

Re:
ID:

Please Provide Training Program Information for the Person Named Above
1.

If you have no record of the person named above, please check the box and return the form. 

2.

Date of enrollment in the training program named above (MM/DD/YYYY):

__/__/___

3.

Date of completion or anticipated date of completion (MM/DD/YYYY):

__/__/___

4.

Please indicate who funded/sponsored the training program (check all that apply).
 U.S. Department of Housing and Urban Development (HUD)
 Another Federal agency
 State government
 Local government
 Other local entity
 Other: ______________________

5.

Does the program have clearly defined goals and objectives?
 Yes  No
IF YES, briefly list or attach a description of those goals and objectives:
______________________________________________________________________________________
______________________________________________________________________________________

6.

What is/was the monthly amount of earnings or other income received because of participation in the
training program? $ _______________

7.

Specify the dates when income was received:
a. From Date (MM/DD/YYYY):

__/__/____

b. Through Date (MM/DD/YYYY):

__/__/____

Return the completed form in the self-addressed, stamped envelope provided by ____/___/____ OR fax the
completed form toll free to: 800-823-0127. If you have any questions, call toll free: 877-392-9776.
Name and title of person completing the form: _______________________________________________________
Signature: ___________________________ Phone Number: _____________________ Date: ____/_____/______
FY 2013 Third Party Verification Request

4

U.S. DEPARTMENT OF HOUSING AND
URBAN DEVELOPMENT
c/o ICF International
Attn: HUDQC
530 Gaither Road, Suite 500
Rockville, MD 20850

To:

Boxes for Official use Only

C/P/C

TPVR-5
Alimony Verification

Macro Link

Re:
ID:

Please Provide Alimony Verification Information for the Person Named Above
1.

If you have no record of the person named above, please check the box and return the form. 

2.

Please provide alimony payment history for the person named above from [17 or 5 months prior to the
QCM] through [QCM] by attaching documents that contain the requested information

3.

Please provide the monthly court ordered alimony amount the person is entitled to: $______________

4.

If you are unable to provide documents to support the requested information, please list the amount of
alimony provided below.

[QCM-5]
[QCM-4]
[QCM-3]
[QCM-2]
[QCM-1]
[QCM]

Alimony Amount
$
$
$
$
$
$

If you are unable to provide the requested information for the entire time period, provide as much information
during that time period as available and an explanation below.
Explanation: __________________________________________________________________________
____________________________________________________________________________________
Return the completed form in the self-addressed, stamped envelope provided by ____/___/____ OR fax the
completed form toll free to: 800-823-0127. If you have any questions, call toll free: 877-392-9776.
Name and title of person completing the form: _______________________________________________________
Signature: ___________________________ Phone Number: _____________________ Date: ____/_____/______
FY 2013 Third Party Verification Request

5

U.S. DEPARTMENT OF HOUSING AND
URBAN DEVELOPMENT

c/o ICF International
Attn: HUDQC
530 Gaither Road, Suite 500
Rockville, MD 20850

TPVR-6
Child Support Verification

Boxes for Official use Only

C/P/C

To:

Macro Link

Re:
ID:

Please Provide Child Support Verification Information for the Person Named Above
1.

If you have no record of the person named above, please check the box and return the form. 

2.

Please list the names of the children on whose behalf support payments were made to the person named
above.
Child’s name
1.__________________________________
2.__________________________________
3.__________________________________
4.__________________________________

3.

Please provide benefit history for all the children listed above from [17 or 5 months prior to the QCM]
through [QCM] by attaching documents that contain the following information clearly labeled:
• Financial Support
• Medical
• Child Care
• Other (list): _______________________

4.

Please provide the monthly court ordered Child Support amount: $______________

5.

If you are unable to provide documents to support the requested information, please list the amount of
child support provided below.
[QCM-5]
[QCM-4]
[QCM-3]
[QCM-2]
[QCM-1]
[QCM]

Financial Support
$
$
$
$
$
$

Medical
$
$
$
$
$
$

Child Care
$
$
$
$
$
$

Other: _________
$
$
$
$
$
$

If you are unable to provide the requested information for the entire time period, provide as much information
during that time period as available and an explanation below.
Explanation: __________________________________________________________________________
____________________________________________________________________________________
Return the completed form in the self-addressed, stamped envelope provided by ____/___/____ OR fax the
completed form toll free to: 800-823-0127. If you have any questions, call toll free: 877-392-9776.
Name and title of person completing the form: _______________________________________________________
Signature: ___________________________ Phone Number: _____________________ Date: ____/_____/______
FY 2013 Third Party Verification Request

6

U.S. DEPARTMENT OF HOUSING AND
URBAN DEVELOPMENT

c/o ICF International
Attn: HUDQC
530 Gaither Road, Suite 500
Rockville, MD 20850

To:

Boxes for Official use Only

C/P/C

TPVR-7
TANF & Other Welfare Verification

Macro Link

Re:
ID:

Please Provide TANF and Welfare Verification Information for the Person Named Above
1.

If you have no record of the person named above, please check the box and return the form.

2.

Please provide benefit history from [17 or 5 months prior to the QCM] through [QCM] by attaching
documents that contain the following information clearly labeled:

3.

4.

5.



• Type of benefit (include child support if being paid through the agency)
• Gross benefit amount
• Medical/other insurance
• Other deductions
Was this person (or other household member) paid for participation in a self-sufficiency or on-the-job
training program?
 Yes  No
IF YES, provide:
• Job Start Date: (MM/DD/YYYY): ___/___/______ Job End Date: (MM/DD/YYYY): ___/___/______
• Monthly amount paid during [QCM] ____/______? $ _____________
Were TANF benefits ever reduced because of fraud or failure of any member to participate in an economic
self- sufficiency program or work activity?
 Yes  No
IF YES:
• What was the date the reduced monthly benefit amount became effective:(MM/DD/YYYY) __/__/____
• What was the amount of the benefit prior to the reduction?
$ ___________
If the person was not receiving benefits as of [QCM] __/___, did the person ever receive TANF benefits?
 Yes  No
IF YES:
• What was the date the monthly benefit amount was stopped:
____/____/___
• What was the amount of the benefit prior to the stoppage?
$ ___________
• List names of persons included in benefit payment: __________________________________
• Indicate why the benefits stopped: _______________________________________________

If you are unable to provide the requested information for the entire time period, provide as much information
during that time period as available and an explanation below.
Explanation: __________________________________________________________________________
____________________________________________________________________________________
Return the completed form in the self-addressed, stamped envelope provided by ____/___/____ OR fax the
completed form toll free to: 800-823-0127. If you have any questions, call toll free: 877-392-9776.
Name and title of person completing the form: _______________________________________________________
Signature: ___________________________ Phone Number: _____________________ Date: ____/_____/______
FY 2013 Third Party Verification Request

7

U.S. DEPARTMENT OF HOUSING AND
URBAN DEVELOPMENT

c/o ICF International
Attn: HUDQC
530 Gaither Road, Suite 500
Rockville, MD 20850

To:

Boxes for Official use Only

C/P/C

TPVR-8
Medical & Disability Expenses
Verification

Macro Link

Re:
ID:

Please Provide Medical and Disability Expense Information for the Person Named Above
1. If you have no record of the person named above, please check the box and return the form. 
2. Please provide a document that lists the monthly out-of-pocket cost of healthcare services or items you
provided the person named above. Please include information for the following 12 months: [11 months prior
to QCM] through [QCM].
Note: Out-of-pocket expenses should only include expenses not covered by health insurance.
The list below includes some common medical and disability expense items. Please provide information
about all the services and items that was rendered by you or your institution to the person named above.
List of healthcare services
• Health insurance premiums
• Services of doctor, nurses, dentists, other healthcare professionals
• Services of health care facility (e.g., hospitals, clinics, labs)
• Medical care of permanently institutionalized individuals
• Care providers (live-in-aides)
• Medical transportation
• Animal services
List of healthcare items
• Prescription medications
• Non-prescription drugs and medical supplies
• Physical impairment assistive devices (hearing aids, eyeglasses)
• Mobility assistance devices, such as wheel chairs
• Special equipment
3. If in addition to the expenses listed above, there was an outstanding balance with incremental payments
being made as of [QCM], please provide the following information.
1.
2.
3.
4.

Type of Expense: _______________
Amount of Outstanding Balance: $ _________
Amount Paid per month: $ _______________
Expected number of payments for the next 12 months: $__________

If you are unable to provide the requested information for the entire time period, provide as much information
during that time period as available and an explanation below.
Explanation: __________________________________________________________________________
____________________________________________________________________________________
Return the completed form in the self-addressed, stamped envelope provided by ____/___/____ OR fax the
completed form toll free to: 800-823-0127. If you have any questions, call toll free: 877-392-9776.
Name and title of person completing the form: _______________________________________________________
Signature: ___________________________ Phone Number: _____________________ Date: ____/_____/______
FY 2013 Third Party Verification Request

8

U.S. DEPARTMENT OF HOUSING AND
URBAN DEVELOPMENT

c/o ICF International
Attn: HUDQC
530 Gaither Road, Suite 500
Rockville, MD 20850

TPVR-9
Child Care Expense Verification

Boxes for Official use Only

C/P/C

To:

Macro Link

Re:
ID:

Please Provide Child Care Information for the Person Named Above
1.

If you have no record of the person named above, please check the box and return the form. 

2.

Please list the names of the children of the person named above for whom you provide child care services
for
Child’s name

Name of person who paid for the child’s care

1.__________________________________

__________________________________

2.__________________________________

__________________________________

3.__________________________________

__________________________________

4.__________________________________

__________________________________

3.

Please provide a history of all child care expenses for the children listed above from [12 month prior to
QCM] through [QCM] by attaching documents that contain only the amounts paid by the person. Include
any amounts paid for each child and the name of the person who paid.

4.

If you are unable to provide documents to support the requested information, please list the amount of
child support provided below.
[QCM-11]
[QCM-10]
[QCM-9]
[QCM-8]
[QCM-7]
[QCM-6]
[QCM-5]
[QCM-4]
[QCM-3]
[QCM-2]
[QCM-1]
[QCM]

Child 1
$
$
$
$
$
$
$
$
$
$
$
$

Child 2
$
$
$
$
$
$
$
$
$
$
$
$

Child 3
$
$
$
$
$
$
$
$
$
$
$
$

Child 4
$
$
$
$
$
$
$
$
$
$
$
$

If you are unable to provide the requested information for the entire time period, provide as much information
during that time period as available and an explanation below.
Explanation: __________________________________________________________________________
____________________________________________________________________________________
Return the completed form in the self-addressed, stamped envelope provided by ____/___/____ OR fax the
completed form toll free to: 800-823-0127. If you have any questions, call toll free: 877-392-9776.
Name and title of person completing the form: _______________________________________________________
Signature: ___________________________ Phone Number: _____________________ Date: ____/_____/______
FY 2013 Third Party Verification Request

9

U.S. DEPARTMENT OF HOUSING AND
URBAN DEVELOPMENT

TPVR-10
Student Gift & Contribution
Verification

Boxes for Official use Only

c/o ICF International
Attn: HUDQC
530 Gaither Road, Suite 500
Rockville, MD 20850

C/P/C

To:

Macro Link

Re:
ID:

Please Provide Information about Gifts and Contribution you have made to the Person Named Above
1. The person named above has stated that you provided financial contributions or paid bills for him/her on a regular
basis. Please provide the amount of money you paid to or for the person named above for the following 6 month
period. If your contribution was something other than money provide the value of the gift or contribution (how
much you paid).
List the Type of Gift or Contribution below
(e.g. money, phone, groceries, clothes,
insurance, car payment, school tuition, rent)

Total

[QCM-5]

[QCM-4]

[QCM-3]

[QCM-2]

[QCM-1]

[QCM]

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

2. The rules for receiving housing assistance from the Department of Housing and Urban Development require
that the parent’s income of all students be taken into consideration unless that student is legally emancipated
from their parents. To determine the amount of housing assistance the person named above should receive
we need the following information:
a. When did the person named above stop living with you? (MM/DD/YYYY): _ _ / _ _ / _ _ _ _
b. Are you claiming the person named above as a dependent on your income tax forms?
 Yes  No
IF NO, when did you stop claiming the person named above as a dependent? (MM/DD/YYYY): _ _ /_ _ / _ _ _ _
3. Please provide the following information regarding your household’s income during _____/______ [QCM]:
Name (List the full name of each
parent or guardian)

Employer Name (list all
employers of
parent/guardian

Annual Amount
received from
the employer

Source of Income other than
Employment (list each
source)

Annual Amount
received from
that source

$

$

$

$

$

$

$

$

If you are unable to provide the requested information for the entire time period, provide as much information
during that time period as available and an explanation below.
Explanation: __________________________________________________________________________
____________________________________________________________________________________
Return the completed form in the self-addressed, stamped envelope provided by ____/___/____ OR fax the
completed form toll free to: 800-823-0127. If you have any questions, call toll free: 877-392-9776.
Name and title of person completing the form: _______________________________________________________
Signature: ___________________________ Phone Number: _____________________ Date: ____/_____/______
FY 2013 Third Party Verification Request

10

U.S. DEPARTMENT OF HOUSING AND
URBAN DEVELOPMENT

TPVR-11
Student Verification

Boxes for Official use Only

c/o ICF International
Attn: HUDQC
530 Gaither Road, Suite 500
Rockville, MD 20850

C/P/C

To:

Macro Link

Re:
ID:

Please Provide Student Status and Financial Assistance Information for the Person Named Above.
1. If you have no record of the person named above, please check the box and return the form. 
2. As of [QCM] ____/____was the person named above a student or planning to be a student at your
institution?
 Yes

 No

IF YES: Please provide the following information
a.

Dates the semester/session immediately prior to or including [QCM] ____/_____ began and ended:
From ____/_____ Thru: ____/______

b.

•

The person’s student status during that semester/session.  Full Time  Part Time  Not a student

•

The cost of tuition and fees for the person named above during that semester/session: $________

Dates the semester/session immediately after or including [QCM] ____/_____ began and ended:
From ____/_____ Thru: ____/______
•

The person’s student status during that semester/session.  Full Time  Part Time  Not a student

•

The cost of tuition and fees for the person named above during that semester/session: $_______

3. According to your records is the person named above a veteran of the U.S. Military?

 Yes

 No

4. Did the person named above receive financial assistance while attending your institution during the period
specified above?
 Yes  No
IF YES: Please provide information about that assistance below. (Attach additional documents, if needed)
Received Date

Type of
Assistance

Amount

Period of Time it Was Intended to Cover

___/_____/______

$

From: ____/_____ Thru: ____/______

___/_____/______

$

From: ____/_____ Thru: ____/______

___/_____/______

$

From: ____/_____ Thru: ____/______

MM

MM

MM

DD

DD

DD

YYYY

YYYY

YYYY

MM

MM

MM

YYYY

YYYY

YYYY

MM

MM

MM

Explain
Stipulations or
Restrictions?

YYYY

YYYY

YYYY

Return the completed form in the self-addressed, stamped envelope provided by ____/___/____ OR fax the
completed form toll free to: 800-823-0127. If you have any questions, call toll free: 877-392-9776.
Name and title of person completing the form: _______________________________________________________
Signature: ___________________________ Phone Number: _____________________ Date: ____/_____/______
FY 2013 Third Party Verification Request

11

U.S. DEPARTMENT OF HOUSING AND
URBAN DEVELOPMENT

TPVR-12
Trust Fund Verification

Boxes for Official use Only

c/o ICF International
Attn: HUDQC
530 Gaither Road, Suite 500
Rockville, MD 20850

C/P/C

To:

Macro Link

Re:
ID:

Please Provide Verification of Trust Fund Information for the Person Named Above.
If you have no record of the person named above, please check the box and return the form. 
Please provide the following information about the trust fund indicated below or any other trust connected with the person
named above.
Trust Identified by
Person Named Above

1.
2.
3.
4.
5.
6.

Any Other Trust

ID # of Trust Fund:
Is the person named above the creator (grantor) or beneficiary?
/
/
/
/
What is the date the trust was established? (mm/dd/yyyy)
Is the trust fund revocable or irrevocable?
If the person named above is the creator of the trust, the trust is irrevocable and was established prior to
(2 yrs prior to QCM) _________/_________, stop here. Sign below and return this form in the enclosed envelope.
If the person named above is the beneficiary, please complete the table below, providing the information for the one-year
period between [QCM] ________/________ and ________/_________ :
Macro Link

Trust Fund ID#

Amount Paid*

How Often Was/Is That Amount Paid?

$
$
* If rate of pay changed during the one-year period indicated above, record each rate of pay and corresponding dates in a separate row

7.

If the person named above is the creator of the trust and the trust is revocable please complete the table below,
providing the information as of [QCM] ________/_________.
Fund Jointly Held?

Macro Link

8.

Trust Fund ID #

Amount of any Payments
Made to any Beneficiaries

Growth Rate
Expected

Cash Value

(annual amount, starting with date
above)

(annual amount, starting
with date above)

$
$

$
$

Cost to Dissolve

If Yes, Held
Jointly
Name of Coholder

$
$

If the person named above is the creator of the trust and the trust is irrevocable but was established between (2 yrs
prior to QCM) _____/_____ and [QCM] _____/_____, please provide the following information as of [QCM]
______/_______:

Macro Link

Trust Fund ID #

Cash Value

$
$
9.

%
%

Yes/No

Name of
Beneficiaries

Amount of any
Payments Made to
any Beneficiaries
(annual amount, starting
with date above)

$
$

Fund Jointly Held?

Growth Rate
Expected
(annual amount,
starting with date
above)

%
%

Cost to
Dissolve

Yes/No

If Yes, Held
Jointly
Name of Coholder

$
$

Does the person named above have access to any funds in the trust that have not been revealed in the questions/tables
above? If yes, what is that amount? $ ____________ (lump sum or annual figure, if applicable).
Explain:______________________________________________________________________________________________

Return the completed form in the self-addressed, stamped envelope provided by ____/___/____ OR fax the
completed form toll free to: 800-823-0127. If you have any questions, call toll free: 877-392-9776.
Name and title of person completing the form: _______________________________________________________
Signature: ___________________________ Phone Number: _____________________ Date: ____/_____/______
FY 2013 Third Party Verification Request

12

U.S. DEPARTMENT OF HOUSING AND
URBAN DEVELOPMENT

c/o ICF International
Attn: HUDQC
530 Gaither Road, Suite 500
Rockville, MD 20850

To:

Boxes for Official use Only

C/P/C

TPVR-13
Life Insurance Verification

Macro Link

Re:
ID:

Please Provide Life Insurance Verification Information for the Person Named Above for All Accounts
Held at Your Institution.
1. If you have no record of the person named above, please check the box and return the form. 
2. Please provide information for each account held by the person named above by attaching documents that
contain the following information clearly labeled:
•
•
•
•
•
•

Life Insurance ID number
Face Value as of the [QCM]
Cash Value as of the [QCM]
Penalty/Fee for Borrowing the Full Cash Value
Annual Income (Interest, Dividends, etc.)
Name of co-owner (if jointly owned)

Return the completed form in the self-addressed, stamped envelope provided by ____/___/____ OR fax the
completed form toll free to: 800-823-0127. If you have any questions, call toll free: 877-392-9776.
Name and title of person completing the form: _______________________________________________________
Signature: ___________________________ Phone Number: _____________________ Date: ____/_____/______
FY 2013 Third Party Verification Request

13

U.S. DEPARTMENT OF HOUSING AND
URBAN DEVELOPMENT

c/o ICF International
Attn: HUDQC
530 Gaither Road, Suite 500
Rockville, MD 20850

Boxes for Official use Only

C/P/C

To:

TPVR-14
Real Estate & Personal Property
Verification

Macro Link

Re:
ID:

Please Provide Information for All Properties Owned by the Person Named Above
1. If you have no record of the person named above, please check the box and return the form. 
2. Please provide the following information for the property indicated below and any other property owned by
the person named above. Provide the information for the month of ____/_____ [QCM].
Asset Held Jointly
As of

Address

Value of Property
As of

Cost to Dispose
(if applicable)
As of

____/_____[QCM]

____/_____[QCM]

$

$

$

$

$

$

$

$

____/____[QCM]

Yes/No

If Asset Held
Jointly, enter
Co-Owner Name

Return the completed form in the self-addressed, stamped envelope provided by ____/___/____ OR fax the
completed form toll free to: 800-823-0127. If you have any questions, call toll free: 877-392-9776.
Name and title of person completing the form: _______________________________________________________
Signature: ___________________________ Phone Number: _____________________ Date: ____/_____/______
FY 2013 Third Party Verification Request

14

U.S. DEPARTMENT OF HOUSING AND
URBAN DEVELOPMENT

TPVR-15
Gift & Contribution Verification

Boxes for Official use Only

c/o ICF International
Attn: HUDQC
530 Gaither Road, Suite 500
Rockville, MD 20850

C/P/C

To:

Macro Link

Re:
ID:

Please Provide Information about Gifts and Contribution you have made to the Person Named Above
The person named above has stated that you provided financial contributions or paid bills for him/her on a regular basis.
Please provide the amount of money you paid to or for the person named above for the following 6 month period. If
your contribution was something other than money provide the value of the gift or contribution (how much you paid).
List the Type of Gift or Contribution below
(e.g. money, phone, groceries, clothes, insurance, car
payment, school tuition, rent)

Total

[QCM-5]

[QCM-4]

[QCM-3]

[QCM-2]

[QCM-1]

[QCM]

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

If you are unable to provide the requested information for the entire time period, provide as much information
during that time period as available and an explanation below.
Explanation: __________________________________________________________________________
____________________________________________________________________________________
Return the completed form in the self-addressed, stamped envelope provided by ____/___/____ OR fax the
completed form toll free to: 800-823-0127. If you have any questions, call toll free: 877-392-9776.
Name and title of person completing the form: _______________________________________________________
Signature: ___________________________ Phone Number: _____________________ Date: ____/_____/______
FY 2013 Third Party Verification Request

15

U.S. DEPARTMENT OF HOUSING AND
URBAN DEVELOPMENT

Boxes for Official use Only

c/o ICF International
Attn: HUDQC
530 Gaither Road, Suite 500
Rockville, MD 20850

C/P/C

To:

TPVR-16
Disability Status Verification

Macro Link

Re:
ID:

Please Provide Disability Status Verification for the Person Named Above.
Please check the box that applied to the person named above, as of _____/_____ [QCM] and complete and sign
the certification of disability.
Certification of Disability
In my professional opinion, __________________________________________ (the person named above)


DID NOT meet the definition of a person with a disability



DID meet the definition of a person with a disability because he/she (check all definitions of persons with
disability listed below that apply):


Was receiving SSI or SSA disability



Was considered to have a disability as defined in Sec. 223 of the Social Security Act (42 U.S.C. 423):

“Inability to engage in any substantial, gainful activity by reason of any medically determinable physical or mental impairment which can be
expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months, or in the case of
an individual who has attained the age of 55 and is blind and unable by reason of such blindness to engage in substantial, gainful activity
requiring skills or ability comparable to those of any gainful activity to which he/she has previously engaged with some regularity and over
substantial periods of time.”


Had a developmental disability as defined in Section 102(7) of the Developmental Disabilities
Assistance and Bill of Rights Act (42 U.S.C. 6001(7)):“Severe chronic disability that: (a) is attributable to a mental or

physical impairment or combination of mental and physical impairments; (b) is manifested before the person attains age 22; (c) is likely to
continue indefinitely; (d) results in substantial functional limitation in three or more of the following areas of major life activity: (1) selfcare,(2) receptive and responsive language, (3) learning, (4) mobility, (5) self-direction, (6) capacity for independent living, (7) economic
self-sufficiency; and (e) reflects the person’s needs for a combination and sequence of special, interdisciplinary, or generic care, treatment, or
other services which are of lifelong or extended duration and are individually planned and coordinated.”


Had a physical, mental or emotional impairment that:

•
•
•

Was expected to be of long continued and indefinite duration,
Substantially impeded his or her ability to live independently, and;
Was of such a nature that the ability to live independently could be improved by more suitable housing conditions.

NOTE:
The definition of a person with a disability DOES NOT EXCLUDE persons who have the disease of acquired
immunodeficiency syndrome (AIDS) or any condition arising from the etiologic agent for AIDS. For purposes of qualifying
for low-income housing, these definitions DO NOT INCLUDE a person whose disability is based solely on any drug or
alcohol dependence.

If you are unable to provide the requested information for the entire time period, provide as much information
during that time period as available and an explanation below.
Explanation: __________________________________________________________________________
____________________________________________________________________________________
Return the completed form in the self-addressed, stamped envelope provided by ____/___/____ OR fax the
completed form toll free to: 800-823-0127. If you have any questions, call toll free: 877-392-9776.
Name and title of person completing the form: _______________________________________________________
Signature: ___________________________ Phone Number: _____________________ Date: ____/_____/______
FY 2013 Third Party Verification Request

16