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201109462 <br /> RECERTIFICATION QUESTIONNAIRE <br /> Property Name: Effective Date: Unit#: <br /> Household Composition: <br /> Relation Date of Gender Social Student If Yes, PT <br /> Name(s) to Head Birth (M/F) Security# (Y/N) or FT <br /> 1 H EAD <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> Please answer the following: Monthly Household Member <br /> Income Source Amount <br /> Employment 1 Yes � No ❑ _ <br /> Employment 2 Yes ❑ No ❑ <br /> Self Employment Yes ❑ No ❑ _ <br /> Social Security Yes ❑ No ❑ <br /> Supplemental Security Income(SSI) Yes ❑ No ❑ <br /> Pension/Veteran's Administration Yes ❑ No ❑ <br /> Child Support/Alimony i'es ❑ No ❑ <br /> TANF/AFDC Yes ❑ No ❑ <br /> Unemployment Benefits Yes ❑ No ❑ <br /> Workers Compensation Yes ❑ No ❑ <br /> Other Yes ❑ No ❑ <br /> Asset Source Cash Value Household Member <br /> Checking Account Yes ❑ No ❑ <br /> Savings Account Yes ❑ No ❑ <br /> Certificate of Deposit Yes ❑ No ❑ <br /> Stocks, Bonds, Mutual Funds Yes ❑ No ❑ <br /> Annuities Yes ❑ No ❑ <br /> Retirement Fund (IRA, Keogh,401K) Yes ❑ No ❑ <br /> Life Insurance(Whole or Universal) Yes ❑ No ❑ <br /> Reat Estate or Rental Property Yes ❑ No ❑ <br /> Disposed of an Asset within last 2 years Yes ❑ No ❑ <br /> Other Yes ❑ No ❑ <br /> Under penalty of perjury, I/we certify that the information presented in this certification is true and accurate to the best of my <br /> knowledge. The undersigned further understand(s)that providing false representation herein constitutes an act of fraud. False, <br /> misleading or incomplete information may result in the termination of a lease agreement. <br /> All household members age 18 or older must sign and date. <br /> Signature (Date) Signature (Date) <br /> Signature (Date) Signature (Date) <br /> (Updated 12/10) <br />