FULL AGENDA PACKET_2021-07-20 - Laserfiche WebLink

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WNOMI1:31WA Earned Income (All forms of earned income must be disclosed for all household members)** ❑ Last three (3) months of consecutive employment check stubs ❑ Cash employment — cash payment history for the last three to six months and most current tax return or IRS verification of non -filing. ❑ Self-employment verification -- most recent complete tax returns, including schedule C or the last three to six months payment history ❑ Other Assets (All asset information must be disclosed for all household members)** For purposes of the PHA, an asset includes the following: 401(k)1403(b), bonds, Certificate of Deposit (CD), checking account, Individual Retirement Account (IRA), inheritances, life insurance policies, money market accounts, mutualfunds, pensions, real property, savings account, stocks, and trustfunds ❑ 3 months consecutive bank statements for all checking and savings accounts ❑ Most recent statement for all other assets (i.e. IRA, 401(k), CD, stocks, bonds, investments, annuities, etc.) ❑ Life insurance —statement/letter showingcash value/surrender value ❑ Last Income Tax Return Filed, including W-2 (i.e. 1040, 540,1099 Schedule C) foreach person who filed ❑ If any member of the family has disposed of an asset valued at more than $1000forless than market value during the past 2 years — provide all documents of sale, transfer bankruptcy, or foreclosures including documents showingany net monetary gain from the transaction ❑ Other Other** ❑ Medical expenses: when medical expenses exceed 3% of your gross annual income - pharmacy printouts, receipts for services and supplies, premium statements, etc., for the last 12 months ❑ Students, if applicable — class schedule and financial aid information ** If unavailable at time of referral, per PIH Notice 2021-14, the PHA will accept an affidavit attesting to reported income, assets, expenses, and other factors which would affect an income eligibility determination. Additionally, applicants may provide documentation that is not dated within 60 days of the PHA's request. For example, an SSI benefit letter issued 11/2020 showingthe 2021 benefit amount and provided 7/2021 would be acceptable. To note, the PHA is still required to verify income against EIV data and is required to follow up on any discrepancies noted between the reported income and EIV data. Any misrepresentation of income received may result in termination from the program. If a statement/affidavit is to be provided in lieu of verification at the time of referral, please use the Statement of Facts form provided in the application packet. Please use a separate form for each adult household member providing said statement/affidavit and for each category above. City Council 31 — 30 7/20/2021 Page 23 of 29