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I TENANT INCOME CERTIFICATION QUESTIONNAIRE I <br />One Form per Adult Member of the Household <br />NAME: TELEPHONE NUMBER: <br />Initial Certification <br />Re -certification <br />Other <br />BIN <br />MONTHLY GROSS INCOME <br />1. <br />❑ <br />❑ <br />1 am self-employed. (List nature of self employment) <br />(use net income from self-employment only) <br />2, <br />❑ <br />❑ <br />1 have ajob and receive wages, salary, overtime pay, commissions, fees, tips, bonuses, and/or <br />other compensation: List fie businesses and/or companies that pay you: <br />Name of Employer <br />$ <br />2) <br />$ <br />3) <br />$ <br />3. <br />❑ <br />❑ <br />I receive cash contributions of gifts including rent or utility payments, on an ongoing basis from <br />persons not living with me. <br />$ <br />4. <br />❑ <br />❑ <br />I receive unemployment benefits. <br />5. <br />❑ <br />❑ <br />I receive Veteran's Administration, GI Bill, or National Guard/Military benefitshocome. <br />6. <br />❑ <br />❑ <br />I receive periodic social security payments. <br />' <br />7. <br />❑ <br />❑ <br />The household receives unearned income from family members age 17 or under (example: <br />Social Security, Trust Fund disbursements, etc.). <br />$ <br />8. <br />❑ <br />❑ <br />1 receive Supplemental Security Income (SSI), <br />9. <br />❑ <br />❑ <br />1 receive disability or death benefits other than Social Security. <br />10. <br />❑ <br />❑ <br />1 receive Public Assistance Income (examples: TANF, AFDC) <br />11. <br />❑ <br />❑ <br />1 am entitled to receive child support payments. <br />❑ <br />❑ <br />1 am currently receiving child support payments. <br />$ <br />If yes, from how many persons do you receive support? <br />$ <br />❑ <br />❑ <br />I am currently making efforts to collect child support owed to me. List efforts being made to <br />collect child support: <br />12. <br />❑ <br />❑ <br />1 receive alimony/spousal support payments <br />13. <br />❑ <br />❑ <br />I receive periodic payments from trusts, annuities, inheritance, retirement funds or pensions, <br />insurance policies, or lottery winnings. <br />$ <br />If yes, list sources: <br />$ <br />1) <br />14. <br />❑ <br />❑ <br />1 receive income from real or personal property. <br />(use net earned income) <br />15. <br />❑ <br />❑ <br />Student financial aid (public or private, not including student loans) <br />Subtract cost of tuition from Aid received <br />$ <br />*For Households receiving Section 8 Assistance Only <br />ASSET INFORMATION <br />YES NO <br />INTEREST RATE CASH VALUE <br />16. ❑ ❑ <br />1 have a checking account(s). <br />If yes, list bank(s) <br />I) <br />% <br />$ <br />2) <br />% <br />$ <br />Tenant Income Questionnaire (July 2018) <br />