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201109462 <br /> 3. ANTICIPATED 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 /> uneamed income amounts onlv),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 /> YES NO Do vou or anvone in vour household have: Annual Amount <br /> Wages or salaries, � <br /> (include overtime,tips,bonuses,commissions and payment received in cash) <br /> Child Support,(includes child suoport vou are entitled to but may not be receiving) $ <br /> Alimony(includes alimony you are entitled to but may not be receiving) $ <br /> Social Security $ <br /> Supplemental Security Income(SSI) � <br /> Public Assistance(General Relief,and/or TANF/AFDC) $ <br /> Veterans Administration Benefits $ <br /> Pension Income $ <br /> Unemployment Compensation � <br /> Income from Tncurance Policies $ _. <br /> Disability,Death Benefits and/or Life Insurance Dividends $ <br /> Worker's Compensation � <br /> Severance Pay $ <br /> Net Income from a Business $ <br /> (including rental property,land contracts or o?her forms of real estate) <br /> Interest,Dividend&Other Income from Net Family Assets $ <br /> Regular Contributions and/or Gifts from Person not residing at unit $ <br /> Lottery Winnings or Inheritances(Paid as an annuity) $ <br /> All regular pay paid to members of the Armed Forces $ <br /> Annuities $ <br /> Retirement Savings Plans(iRA/401K/Keogh) � <br /> Education Grants,Scholarships or Other Students Benefits $ <br /> Self Employment � <br /> Other $ <br /> TOTAL $ <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 /> YES NO Do vou or anvone in vour household have: Cash Value <br /> A Savings Account? $ <br />