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INCOME VERIFICATION FORM <br />Monthly Gross Income <br />List All Sources of Income of All Household Members Living in the Affordable Unit <br />Part 1: Earned Income <br />Other <br />Head of <br />Household <br />Household <br />Members <br />Total <br />1. <br />Gross wages, before payroll deductions and <br />$ <br />$ <br />$ <br />including overtime pay, commissions, fees, tips <br />and bonuses. <br />2. <br />Net income from self employment, independent <br />$ <br />$ <br />$ <br />contractor work or a business. <br />3. <br />Social security and any payments from annuities, <br />$ <br />$ <br />$ <br />insurance policies, pension/retirement funds, <br />disability or death benefits received periodically. <br />4. <br />Payment in lieu of earnings, such as <br />$ <br />$ <br />$ <br />unemployment, disability compensation, worker's <br />compensation and severance pay. <br />5. <br />Public assistance, welfare payments <br />$ <br />$ <br />$ <br />6. <br />Alimony, child support, other periodic allowances <br />$ <br />$ <br />$ <br />7. <br />Regular pay, special pay and allowances of <br />$ <br />$ <br />$ <br />members of the Armed Forces <br />8. <br />Other <br />$ <br />$ <br />$ <br />Subtotal: Monthly Earned Income $ <br />Total Monthly Earned Income x 12 = $ Total Annual Household Gross Earned Income <br />INCOME VERIFICATION FORM <br />Monthly Gross Income <br />Page 65 <br />Exhibit E <br />55394.00101\43721567.2 <br />