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South Bend Lead Protection Program <br />FORM B – Supporting documents for <br />Need help? Contact Daniela Bautista-Amick dbautista-amick@southbendin.gov or 574-245- <br />6085 <br />Page | 3 <br /> <br /> <br />About me Supporting documents Directions <br /> <br />1 Check all <br />statements that <br />apply to you. <br />2 Check the documents you need to <br />submit. We accept photos (one-page <br />documents only), electronic, and paper <br />copies. <br />3 Read directions for gathering <br />the right documents. <br /> Bank statements and assets documents <br />About me Supporting documents Directions <br /> <br /> I have a checking <br />account. <br /> 6 most recent checking account <br />statements <br />The statements must include the name <br />of the financial institution, all pages, your <br />name, account number, balance sheet, <br />and detail of transaction. <br /> <br /> I have a savings <br />account. <br /> Most recent savings account statement The statement must include the name of <br />the financial institution, all pages, your <br />name, account number, balance sheet, <br />and detail of transaction. <br /> <br /> I have assets other <br />than money in <br />banks. <br /> 2 most recent statements for each asset <br />such as: <br />• Other savings <br />• Investments <br />• Retirement <br />• Stocks <br />Statements might be provided monthly, <br />quarterly, or yearly. <br /> <br />Provide 2 most recent statements no <br />matter how often you get them. <br /> <br /> I do not have a <br />bank account or <br />assets. <br /> Required documents pending contact with <br />Daniela Bautista-Amick <br />Contact Daniela Bautista-Amick at <br />574-245-6085 to figure out a way to <br />show this in your file. <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Continue to next page <br />