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201109462 INSTRUCTIONS FOR COMPLETING TENANT INCOME CERTIFICATION The Tenant Income Certi fication form is to be completed by the owner or an authorized representative. Part I—Development Data Check the appropriate box for Initial Certification(move-in),Recertification(annual recertification)or Other. If Other,designate the purpose of the recertification(i.e.,a unit transfer,a change in household composition or other state-required recertification). Move-in Date: Enter the date the tenant has or will take occupancy of the unit. Effective Date: Enter the effective date of the certification. For move-in,this should be the move-in date. For annual recertification,this effective date sfiould be no later than one year from the effective date of the previous(re)certification. Property Name: Enter the name of the development. County: Enter the county(or equivalent)in which the building is located. BIN#: Enter the Building Identification Nkmber(BIN)assigned to the building(from IRS Form 8609). Address: Enter the address of the building. Unit Number: Enter the unit number. #Bedrooms: Enter the m�mber of bedrootns in the unit. Part II—Household Composition Name: List first name,middle initial and last name of all occupants in the unit. Relationship to Head Enter each household member's relationship to the head of household by using one of the following coded of Household: definitions: H - Head of Household S - Spouse A - Adult co-tenant O - Other family member C - Child F - Foster child(ren)/adult(s) L - Live-in caretaker N - None of the above Race: Enter each household member's race by using the following coded definitions: 1 - White 2 - Black/African American 3 - American Indian/Alaska Native 4 - Asian 5 - Native Hawaiian/Other Pacific Islander *More than one race may be checked for each household member Ethnicity: Enter each household member's ethnicity by using one of the following coded definitions: 1 - Hispanic or Latino 2 - Not Hispanic or Latino Disabled?: Enter Yes if any member of the household is disabled according to Fair Housing Act definition for handicap (disability): . A physical or mental impairment which substantially limits one or more major life activities;a record of such an impairment;or being regarded as having such an impairment. For a definition of"physical or mental impairmenY'and other terms used in this definition,please see 24 CFR 100.201,available at htt��;%��-��r�fiirhotisin�;i;oi��!in<l�r cfin`�n�eChuci=��;e.displav&��a�en��me—re�,�s f17r 7(}(}_?O1 . . "Handicap"does not include current,illegal use of or addition to a controlled substance.