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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 Household <br /> Household Members Total <br /> 1. Gross wages, before payroll deductions and $ $ $ <br /> including overtime pay, commissions, fees, tips <br /> and bonuses. <br /> 2. Net income from self employment, independent $ $ $ <br /> contractor work or a business. <br /> 3. Social security and any payments from annuities, $ $ $ <br /> insurance policies, pensionlretirement funds, <br /> disability or death benefits received periodically. <br /> 4. Payment in lieu of earnings, such as $ $ $ <br /> unemployment, disability compensation, worker's <br /> compensation and severance pay. <br /> 5. Public assistance, welfare payments $ $ $ <br /> 6. Alimony, child support, other periodical Iowa nces $ $ $ <br /> 7. Regular pay, special pay and allowances of $ $ $ <br /> members of the Armed Forces <br /> 8. Other $ $ $ <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 /> Exhibit E Page 65 <br /> 55394.00101\43721567.1 <br />