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. TENANT INCOME CERTIFICATION <br />❑ Initial Certification ❑ Recertification ❑ Other <br />Effective Date: <br />Move -In Date: <br />MM-DD-YYYY) <br />PART I - DEVELOPMENT DATA <br />Property Name: County: TCAC#: BIN#: <br />Address: If applicable, CDLAC#: <br />Unit Number: # Bedrooms: Square Footage: <br />PART II. HOUSEHOLD COMPOSITION <br />❑ Vacant (Check if unit was vacant on December 31 of the Effective Date Year <br />141-1 <br />Mbr# <br />Last Name <br />First Name <br />Middle <br />Initial <br />Relationship to Head <br />of Household <br />Date of Birth <br />(MM/DD/YYYY) <br />Student Status <br />(Check One) <br />Last 4 digits of <br />Social Security <br />1 <br />HEAD <br />FTO/PTOMA❑ <br />2 <br />FTO/PTO/NA❑ <br />3 <br />FrO/PTOMA❑ <br />4 <br />FTO/PTEIMA❑ <br />5 <br />FTO/PT/NA❑ <br />6 <br />FTIJVTOMAD <br />% <br />FTO/PTOMAD <br />PART IH. GROSS ANNUAL INCOME USE ANNUAL AMOUNTS <br />Mbr# <br />(A) <br />Employment or Wages <br />(B) <br />Soc. Security/Pensions <br />(C) <br />Public Assistance <br />(D) <br />Other Income <br />NHE <br />TOTALS <br />$ <br />$ <br />$ <br />$ <br />Add totals from (A) through (D), above TOTAL INCOME (E): <br />$ <br />PART IV. INCOME FROM ASSETS <br />HH <br />Mbr # <br />(F) <br />Type of Asset <br />(0) <br />C/I <br />(H) <br />Cash Value of Asset <br />(I) <br />Annual Income from Asset <br />TOTALS: $ $ <br />Enter Column (H) Total Passbook Rate <br />Ifover $5000 $ X 0.06% _ (J) Imputed Income $ <br />Enter the greater of the total of column I, or J: imputed income TOTAL INCOME FROM ASSETS (IC) $ <br />(L) Total Annual Household Income from all Sources [Add (E) + (K)] <br />$ <br />HOUSEHOLD CERTIFICATION & SIGNATURES <br />The information om this form will be used to determine maximum income eligibility. I/we have provided for each person(s) set forth in Part 11 acceptable verification of <br />current anticipated annual income. Uwe agree to notify the landlord immediately upon any member of the household moving out of the unit or any new member <br />moving in. I/we agree to notify the landlord immediately upon any member becoming a full time student. <br />Under penalties of perjury, I/we certify that the information presented in this Certification is true and accuratem the best of my/our knowledge and belief. The undersigned <br />further understands that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination of <br />the lease agreement. <br />Signature (Date) signature (Dale) <br />Signature <br />(Date) Signature <br />Tenant Income Certification (April 2021) <br />