FULL AGENDA PACKET_2021-07-20 - Laserfiche WebLink

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TENANT INFORMATION FORM Part 4: Household Expenses 1. Does any adult household member (age 18 or older) attend school full time? (If yes, provide current enrollment and financial aid information from registrar or admissions officer and enter contact L Yes L No information in the section below.) 2. Does any member of your family have UNREIMBURSED expenses for care of a child age 12 or younger so that an adult family member can work? E Yes E No 3. Does any member of your family have UNREIMBURSED expenses for care of a person with disabilities so that an adult family member can work? C Yes [ No 4. ONLY complete the following if the head of household, spouse or co-head is age 62 or older, or has a disability. Does any member of your family have UNREIMBURSED medical expenses (i.e. Medical Insurance Premiums; Medical, Dental, or Optical Expenses; or Expenses for Prescription/Non Prescription [ Yes [ No Medicines (prescribed by a physician))? Review and update the following expense information relating to questions marked as Yes in the lines above. Additional expenses must be entered in the space provided below. DOCUMENTATION REQUIRED: Provide documentation from Verification Source listing the monthly payment for each expense and check the Documentation Attached box for each expense. Member Name Allowance Type Monthly Payment $ Current Expense Vey i� No Documentation Attached i� Yes No Verification Source Name and Address Member Name Allowance Type Monthly Payment $ Current Expense Yes L] No Documentation Attached Yes No Verification Source Name and Address Member Name Allowance Type Monthly Payment $ Current Expense u Yes L-1 No Documentation Attached Yes No Verification Source Name and Address Member Name Allowance Type Monthly Payment $ Current Expense Yes a No Documentation Attached Yes No Verification Source Name and Address Member Name Allowance Type Monthly Payment $ Current Expense Yes a No Documentation Attached J Yes No Verification Source Name and Address Member Name Allowance Type Monthly Payment $ Current Expense D Yes D No Documentation Attached Yes No Verification Source Name and Address Attach Additional Sheets if Necessary Part 5: Head of Household Must Sign this Form Certifying Accuracy of Information Provided I certify that the information on this form is true and complete to the best of my knowledge and belief. I understand that I can be fined up to $10,000, or imprisoned up to five years if I furnish false or incomplete information. Name Date Pace 4 City Council 31 — 18 7/20/2021 Page 11 of 29