Bank Verification Form Sample
Letter 0011 Bank Verification/SAIL
BANK VERIFICATION FORM
Control Number __________________
Please complete Section I and have a bank official complete Section II of this form. We will deny, stop
or change your benefits if you do not return this form within 10 days.
Section I (to be completed by client):
I, _______________________________ of ________________________________________________
Name Address
authorize_____________________________________________________________________________
Name of Bank
to release information concerning bank accounts to the Department of Social Services.
Signature:
Date:
Section II (To be completed by bank):
Please provide the following information for the above client and family members:
Checking Accounts
Account Number
Account Number
Account Name
Account Name
Balance $
Balance $
Savings Accounts
Account Number
Account Number
Account Name
Account Name
Balance $
Balance $
Other Accounts
Type of Account
Type of Account
Account Name
Account Name
Account Number
Account Number
Balance $
Balance $
Signature:
Date:
Bank Official
Telephone Number:
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