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'1ENAN -F RECEKr1FJCAl'lON for YKOYlt;K1Y WEY11WAIVER 20051260E Effective Dam / Movaia Iota (MM / AD / YYYY) County: BIN #: Property Name: Unit #: #'Bedrooms: Address: Name a Tenant$: (Z•) (4.) (3•) Anticipated Annual lncame for the (1). Income from salary, wages, commissions, self employment, etc.: i) S (x). Income front Not Family Assets C NFA'I: (i) If NFA does not exceed $5,000, then crack "No" on line (a); enter the amount of Actual Income from NFA on line 2; (ii) If NFA is Greater than $5,000, then check "Yet" amount line (aAc )t�1/PacPected Annual total amotmt of NFA on line (b); Cofer Income from NFA on line (c); enter amount of Imputed Annual Iwo= from NFA on line (0, and finally, enter the Greater of line (c) or (d) on line 2. a) Tenant's NFA exceeds $5,000 ❑ YES ❑ NO b) Tesumes NFA equals: $ c) Tenant's Actual/Expectad Annual Income from NFA: S or, d) Imputed Annual income from NFA: line (b) x (2 0%): S x) s (3) Total income add 0 + 2) above 3) s ARE ALL OCCUPANTS FULL-TIME STUDENTS ". ❑ Yes (:1 No if Yes, enter student exception explanation Stud nt ce n Ilan n: 1) Single ANF/ FDC�a assistance 4) Married /Joint tax Or return ent P° Under penalties of perjt:tY, 1 /we certify that the information presented in this Certification is true and accurate to the best of my /ou knowledge and belief. The undersigned further understands that providing false representation herein constitutes an act of fraud. False misleading or incomplete information may result in the termination of the lease agreement. Date 1.) 7anattt Signature 2.) Tenant Signature date Date 3.) Tenant Signature Date a Tenant Signature TmS9CTIOH TO I3E'.C6MPdTED Y PROIEG I VER/O O WV✓[ N)»[t "3 R �Pi ENFATIYE , Maximum income level for number of tenants) is S x 140% T $ The undersigned Project Owner hereby certifies, that the preceding infon-nation is true and correct to the best of his cr her knowledge. Date Owner: Representative Signature (,;pd„ed 12 Ca)