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201109462 <br /> TENANT INCOME CERTIFICATION <br /> ❑ Initial Cer[ification ❑ ReceRification ❑ Other: Effective Date: / / <br /> Move-in Date: / / <br /> (MM/DD/YYYY) <br /> PART L DEVELOPMENT DATA <br /> Property Name: County: B[N#: <br /> Address: Unit Number: #Bedrooms: <br /> PART II.HOUSEHOLD COMPOSITION <br /> Relationship <br /> Hshold First Name&Middle Date of Birth F/T Student Last four digits of <br /> Mbr# Last Name Initial to Head of Race Ethnicity Disabled? �MM/DD/YYYY) (Y or N) Social Security# <br /> Household <br /> 1 <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 6 <br /> 7 <br /> PART IIL GROSS ANNUAL INCOME(USE ANNUAL AMOUNTS) <br /> Hshld (A) (B) (C) (D) <br /> Mbr# Employment or Wages Soc.Security/Pensions Public Assistance Other Income <br /> TOTALS $ � $ � <br /> Add totals from(A)through(D),above-- TOTAL INCOME(E): c� <br /> PART IV. INCOME FROM ASSETS <br /> Hshld (F) (G) (H) (1) <br /> Mbr# Type of Asset GI Cash Value of Asset Annual Income From Asset <br /> TOTALS: $ $ <br /> Enter Column(H)Total Passbook Rate <br /> If over$5,000 $ x 2.00%_ (J)Imputed Income $ <br /> Enter the�reater of the total of column I or J(imputed income). TOTAL INCOME FROM ASSETS(K) $ <br /> (L)Total Annual Household Income From All Sources[Add(E)+(K)] $ <br /> HOUSEHOLD CERTIFICATION&SIGNATURES <br /> The information on this form will be used to determine maximum income eligibility. I/we have provided for each person(s)set forth in Part Il acceptable verification of <br /> current anticipated annual income. t/we agree to notify the landlord immediately upon any member of the household moving out of the unit or any new member moving in. <br /> 1/we agree to notify the landlord immediately upon any member becoming a full-time student. <br /> Under penalties or perjury,I/we certify that the information presented in this Certification is true and accurate to the best of my/our knowledge and belief. The undersigned <br /> further understands that providing false representations herem constitutes an act of fraud. False,misleading or incomplete information may result in the termination of the <br /> lease agreement. <br /> Signature Date Signature Date <br /> Signature Date Signature Date <br />