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EXHIBIT B -1 200109053 APPLICATION AND INCOME CERTIFICATION FEDERAL TAX CREDIT PROGRAM Effective Date: ❑ Initial Certification ❑ Recertification ❑ Other Move -in Date: (MM /DD /YYYY) PART I. DEVELOPMENT DATA Property Name: County: BIN #: Address: Unit Number: # Bedrooms: PART II. HOUSEHOLD COMPOSITION Hshld Mbr # Last Name First Name & Middle Initial Relationship to Head of Household Date of Birth (MN /DD /YYYY) F/T Student (Y or N) Social Security or Alien Reg. No. 1 HEAD 2 3 4 $ $ $ $ Add totals from (A) through (D), above -- TOTAL INCOME (E): $ 5 $ $ (L) Total Annual Household Income from all Sources [Add (E) + (K)] $ 6 7 PART III. GROSS ANNUAL INCOME (USE ANNUAL AMOUNTS) Hshld Mbr # (A) Employment or Wages (B) Soc. Security/Pensions (C) Public Assistance (D) Other Income (G) C/I (H) Cash Value of Asset (I) Annual Income from Asset TOTALS $ $ $ $ Add totals from (A) through (D), above -- TOTAL INCOME (E): $ HOUSEHOLD CERTIFICATION & SIGNATURES The information on this form will be used to determine maximum income eligibility. Uwe have provided for each person(s) set forth in Part II acceptable verification of 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 moving in. Uwe agree to notify the landlord immediately upon any member becoming a full -time student. Under penalties or perjury, Uwe certify that the information presented in this Certification is true and accurate to the best of my /our knowledge and belief. The undersigned further understands that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination of the lease agreement. Signature (Date) Signature (Date) 01- 351904.01 i PART IV. INCOME FROM ASSETS Hshld Mbr # (F) Type of Asset (G) C/I (H) Cash Value of Asset (I) Annual Income from Asset TOTALS: $ Enter Column (H) Total Passbook Rate If over $5000 $ X 2.00 % = (J) Imputed Income Enter the greater of the total of column I, or J (imputed income) TOTAL INCOME FROM ASSETS (K) $ $ $ (L) Total Annual Household Income from all Sources [Add (E) + (K)] $ HOUSEHOLD CERTIFICATION & SIGNATURES The information on this form will be used to determine maximum income eligibility. Uwe have provided for each person(s) set forth in Part II acceptable verification of 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 moving in. Uwe agree to notify the landlord immediately upon any member becoming a full -time student. Under penalties or perjury, Uwe certify that the information presented in this Certification is true and accurate to the best of my /our knowledge and belief. The undersigned further understands that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination of the lease agreement. Signature (Date) Signature (Date) 01- 351904.01 i