HomeMy WebLinkAboutExhibit C calculating part 5 annual income formExhibit C
Affordable Housing Income Qualification Form
Units in this building may be available to households that meet certain income qualifications. To determine if your household is eligible for
such a unit, please complete this entire form. If there are any questions that you do not understand, please contact the property manager.
A.CONTACT INFORMATION
Current Address: Apt #:
City/State/Zip: Phone: ( )
C.HOUSEHOLD ASSETS (Identify if anyone has any of the following types of assets, including dependents under the age of 18)
Identify All Asset Sources Name on Account Financial Institution Cash Value Income from Asset
(Interest/Dividends)
Checking Account Yes No
Additional Checking Account(s) Yes No
Savings Account Yes No
Additional Savings Account(s) Yes No
Stocks, Bonds, Mutual Funds* Yes No
Real Estate or Home Yes No
IRA/Keogh Account* Yes No
Retirement/Pension Fund* Yes No
Trust Fund/Inheritance Yes No
Real Estate/Land* Yes No
Other: Yes No
Totals:
*When listing the “cash value” of any asset with an asterisk, state the amount you would have if you were to convert it to cash. The cash value should not
include any penalties for withdrawal, amounts used to pay off a balance, or any fees which may be assessed for the conversion.
B.HOUSEHOLD COMPOSITION – List the Head of Household and all other persons who comprise the household
Full Name
Relationship to
Head of
Household
Date of Birth Gender Race Ethnicity Disabled? Student Status Receiving
Income?
1
Head of
Household Yes No Full-
Time
Part-
Time N/A Yes No
2 Yes No Full-
Time
Part-
Time N/A Yes No
3 Yes No Full-
Time
Part-
Time N/A Yes No
4 Yes No Full-
Time
Part-
Time N/A Yes No
5 Yes No Full-
Time
Part-
Time N/A Yes No
D. ANNUAL INCOME (List ALL income of adults and children in your household, except for the earned income from
employment by persons under the age of 18)
Identify income from any of the following sources,
including periodic payments:
Name Source of Income Amount Received Time Received Annual
Amount
Salary Yes No
Overtime Pay Yes No
Commissions/Fees Yes No
Tips and Bonuses Yes No
Salary from 2nd job Yes No
Temporary Income Yes No
Income from Military Yes No
Interest/Dividends Yes No
Business Net Income Yes No
Net Rental Income Yes No
Social Security Yes No
Supplemental Security Income Yes No
Pension Yes No
Retirement Funds Yes No
Familial Support Yes No
Unemployment Benefits Yes No
Workers’ Compensation Yes No
Alimony Yes No
Child Support (Circle Type) Yes No
Anticipated, Voluntary, Court Ordered (regardless if pd)
Educational Scholarship/Grant Yes No
Other:
Explain:
Yes No
Total:
E. APPLICANT CERTIFICATION
RELEASE: I/We hereby certify that the information provided in this application is true and correct to the best of my/our
knowledge. If approved for an affordable unit, I/we understand that I/we will need to recertify our income annually if I/we
choose to renew our lease.
Applicant/Resident Printed Name Signature Date
Co-Applicant/Resident Printed Name Signature Date
F.THIS SECTION TO BE COMPLETED BY PROPERTY MANAGER/OWNER
Applicant Name Household Size
Cash Value of Assets A. Income from Assets B.
If Line B is greater than $5,000, multiply by .06%,
otherwise enter $0. This is income from assets C.
Annual Income D.
Total Household Income (add lines C + D) E.
Above or Below 60% AMI Does Household Qualify? Yes No
Applicant’s household income is sufficient to pay rent and necessary bills
(utilities, groceries, transportation, etc.)? Yes No
Comments
Signature of Agency Representative Agency Date