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200809274 UNDER $5,000 ASSET CERTIFICATION 2i\6WD68 For households whose combined net assets do not exceed $5,000. Complete only one form per household; include assets of children. Unit#: Household Name: Development Name: City: Complete all that apply for 1 through 4: 1. My/our assets include: (A) (B) (A'B) Cash Int. Annual Value . Rate Income $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Source (A) (B) (A'B) Source Cash Int, Annual Value , Rate Income Savings Account $ $ Checking Account Cash on Hand $ $ Safety Deposit Box Certificates of Deposit $ $ Money market funds Stocks $ $ Bonds IRA Accounts $ $ 401 K Accounts Keogh Accounts $ $ Trust Funds Equity in real estate $ $ Land Contracts Lump Sum Receipts $ $ Capital investments Life Insurance Policies (excluding Term): Other RetirementfPension Funds not named above: Personal property held as an investment**: Other (list): PLEASE NOTE: Certain funds (e.g., Retirement, Pension, Trust) mayor may not be (fully) accessible to you. Include only those amounts which are. 'Cash value is defined as market value minus the cost of converting the asset 10 cash, such as broker's fees, settlement costs, outstanding loans, early withdrawal penalties, etc. "Personal property held as an investment may include, but is not limited to, gem or coin collections, art, antique cars, etc. Do not include necessary personal property such as, but not necessarily limited 10, household fumimre, daily.use autos, clothing, assets of an active business, or special equipment for use by the disabled. MUST CHECK BOX 2 OR 3. 2. D Within the past two (2) years, I/we have sold or given away assets (including cash, real estate, etc.) for more than $1,000 below their fair market value (FMV). Those amounts t are included above and are equal to a total of $ (t the difference between FMV and the amount received, for each asset on which this occurred). 3. D 4. D I/we have not sold or given away assets (including cash, real estate, etc.) for less than fair market value during the past two (2) years. I/we do not have any assets at this time. The net family assets (as defined in 24 CFR 813.102) above do not exceed $5000 and the annual income from the net family assets is $ . This amount is included in total gross annual income (Complete even ifthe amount is 0). Under penalty orperjury, l/we certify that the information presented in this certification is true and accurate to the best ormy/our knowledge. The undersigned further understand(s) that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in lhe termination of a lease agreement. ApplicantlTenant Date Applicant/Tenant Dale ( Updated 11/07)