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Name: Michael Miller DOB: 01/01/1980 Address: 123 Main Street, Indianapolis, IN

I do not have the 2014 Honda Civic anymore and I don’t have any paperwork on it. It broke down and was towed away by the city around August of 2022.

This is information is complete and correct to the best of my knowledge.

Signature

Date Note: This does not apply when an applicant/recipient is failing to cooperate with the Authorized Representative or third party in securing required documentation. In these cases, the worker must reach out to the applicant/recipient to determine whether the applicant/recipient has attempted to cooperate with obtaining verifications and needs assistance. An Authorized Representative’s statement that they cannot obtain the verifications from their client cannot stand in for the required documentation. If there is a question as to whether a submission or statement is sufficient, send to PAL for review before taking an adverse action on the case. 2025.15.00 REQUESTS FOR INFORMATION If the worker requires information or verification from the individual, he must provide the individual with the following: • A written list of specific information required to complete the application process • The date the information is due. • Information on the consequences of not returning additional information by the due date.18