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<br />200809274 <br /> <br />2VOID968 <br /> <br />3. ANTlCIP A TED HOUSEHOLD INCOME: PRESENT EMPLOYMENT AND OTHER INCOME RECEIVED BY <br />HOUSEHOLD MEMBERS: For the following indicate the amount of anticipated income for all household members (for minors, <br />unearned income amounts only), during the 12 months period beginning this date, If you are uncertain which types of income must be <br />included or may be excluded, please ask the management personnel for assistance. <br /> <br />YES <br /> <br />NO <br /> <br />Do vou or anvone in your household have: <br /> <br />Annual Amount <br /> <br />Wages or salaries, $ <br />(include overtime, tips, bonuses, commissions and payment received in cash) <br /> <br />Child Support. (includes child support You are entitled to but may not be receiving) $ <br /> <br />Alimony (includes alimony you are entitled to but may not be receiving) $ <br /> <br />Social Security $ <br /> <br />Supplemental Security Income (SSI) $ <br /> <br />Public Assistance (General Relief: and/or TANF/AFDC) $ <br /> <br />Veterans Administration Benefits $ <br /> <br />Pension Income $ <br /> <br />Unemployment Compensation $ <br /> <br />Income from Insurance Policies $ <br /> <br />Disability, Death Benefits and/or Life Insurance Dividends $ <br /> <br />Worker's Compensation $ <br /> <br />Severance Pay $ <br /> <br />Net Income from a Business $ <br />(including rental property, land contracts or other forms of real estate) <br /> <br />Interest, Dividend & Other Income from Net Family Assets $ <br /> <br />Regular Contributions and/or Gifts from Person not residing at unit $ <br /> <br />Lottery Winnings or Inheritances (Paid as an annuity) $ <br /> <br />All regular pay paid to members of the Armed Forces $ <br /> <br />Annuities $ <br /> <br />Retirement Savings Plans (IRA/40I K/Keogh) $ <br /> <br />Education Grants, Scholarships or Other Students Benefits $ <br /> <br />Self Employment $ <br /> <br />oo~ $ <br /> <br />TOTAL $ <br /> <br />4. ASSET INCOME: List all assets currently held by all household members and the cash value of each. The cash value is the market value <br />of the asset minus reasonable costs there was, or would be, incurred in selling or converting the asset to cash. <br /> <br />YES <br /> <br />NO <br /> <br />Do you or anyone In your household have: <br /> <br />Cash Value <br /> <br />A Savings Account? <br /> <br />$ <br />