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201109462 SELF-EMPLOYMENT AFFIDAVIT You have applied to live in an apartment that is governed by the federal government's Housing Credit Program. This Program requires us to certify all of your income,assets and eligibility information as part of determining your household's eligibility. Program requirements state we must verify each income and asset source as well as other claims of eligibility. We must determine this prior to granting your eligibility and,if such eligibility is granted,each subsequent year you remain in the unit. COMPLETE THIS FORM IN ITS ENTIRETY I hereby attach copies of my individual federal tax returns for the immediate preceding three calendar years for which self employment tax returns could have been filed(or,if not filed,were not required to be filed)and certify that the information shown in such income tax returns is hue and complete to the best of my knowledge. Business income counted towards income eligibility for the Housing Credit Program is net income from the operation of a business or profession,including cash withdrawals from the business.Do NOT deduct accelerated depreciation,payments made to expand the business or principal payments on debt. Name�f$�siness: BusinPss Address: Type of Business: City,State,Zip: Position Held• Start Date: Anticipated Annual Income: $ �`umber of Self-Employment Federal Tax Returna filed in Qhe last three years:__ tax return income:$ (Year o� tax return income:$ (Year o� tax return income:� (Year o� Average: $ NOTE: • If anticipated annual income is greater than the average of the tax returns,include the anticipated annual income. • [f anticipated annual income is less than the average of the tax returns,provide explanation;otherwise,include average of the tax returns. Attach a copy of your SIGNED or electronically submitted Federal Tax Return including ProfidLoss Statement (Schedule C)for preceding three calendar years. If this is a new business,or if you do not file income taxes,you will need to provide an anticipated ProfiULoss Statement or a written business plan. Under penalty of perjury,I certify that the information presented in this certification is true and accurate to the best of my knowledge. The undersigned further understands that providing false representation herein constitutes an act of fraud. False,misleading or incomplete information may result in the termination of a lease agreement. Signature of Applicant/Resident Printed Name Date (Updatcd 12/10)