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200809274 TENANT INCOME CERTIFICATION 2WmP68 o Initial Certitlcation o Recertification o Other: Effective Date: Move-in Date: / / (MM / DO / YYYY) PART I. DEVELOPMENT DATA Property Name; County: BIN#; Address: Unit Number: # Bedrooms: PART II. HOUSEHOLD COMPOSITION Hshld first Name & Middle Relationship to Head of Date of Birth F/T Student Social Security Mbr# Last Name Initial Household (MM/l)DIYYYY) (Y or N) or Alien Reg. No. I HEAD 2 3 4 5 6 7 PART III. GROSS ANNUAL INCOM[ (USE ANNUAL AMOUNTS) Hshld (A) (B) (C) (D) Mbr# Employment or Wages Soc. Security/Pensions Public Assistance Other Income TOTALS $ $ $ $ Add totals from (A) through (D). above -- TOTAL INCOME (E): $ PART IV. INCOME FROM ASSETS Hshld (F) (G) (H) (I) Mbr# Type of Asset C/I Cash Value of Asset Annual Income from Asset TOTALS: $ $ Enter Column (H) Total Passbook Rate If over $5.000 $ x 2.00% = (J) Imputed Income $ Enter the lIl'catcr ofthe total of column I or J (imputed income). TOT AI. INCOME FROM ASSETS (K) $ (L) Total Annual Household Income From All Sources [Add (E) + (K)] $ I HOUSEHOLD CERTIFICATION & SIGNATURES The information on this form will be useu to determine maximum income eligibility. I1we have provided for each person(s) set forth in Part II acceptable verification of current anticipated annual income. I/we agree to notify the landlord immediately upon any member of the householu moving out of the unit or any new member moving in. I/we agree to notify the landlord immediately upon any member becoming a full-time srudem. Under penalties or perjury, I/we certify that the information presented in this Certification is true and aeCUrale 10 the best of my/our knowledge and belief. Thc undersigned further unuerstands that providing false representations herein constirutes an act of fraud. false, misleading or incomplete information may result in the termination of the lease agreemem. Signature (Date) Signamre (Date) Signature (Dale) Signamre (Dale)