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TENANT INCOME VERIFICATION FORM <br />Gross Income * <br />List All Sources of Income of All Household Members Living in the Inclusionary Unit <br />Part 2: Investment Income <br />Interest paid on Bank and Savings accounts <br />2. Dividends and other payments from stocks and <br />bonds <br />3. Income from real property (i.e. rental property) <br />4. Other (describe) I <br />Subtotal: Monthly Investment Income: <br />Total Monthly Investment Income <br />E <br />Head of <br />Household <br />Other Adult <br />Household <br />Members <br />Household <br />Investment <br />Income <br />Total Annual Household Investment Income <br />*Note: The following items are ed income: casual or sporadic gifts; amounts specifically for or in <br />reimbursement of medical expenselWp sum payments such as inheritances, insurance payments, capital <br />gains and settlement for personal or property losses; educational scholarships paid directly to the student or <br />educational institution; special pay to a serviceman head of family away from home and under hostile fire; <br />relocation payments under federal, state or local law; foster child care payments; value of coupon allotments <br />for purpose of food under Food Stamp Act of 1964 which is in excess of amount actually charged the eligible <br />household; payments received pursuant to participation in the following programs: VISTA, Service Learning <br />Programs, and Special Volunteer Programs, SCORE, ACE, Retired Senior Volunteer Program, Foster <br />Grandparent Program, Older American Community Services Program, and National Volunteer Program to <br />Assist Small Business Experience. <br />Tenant Income Verification Form <br />Santa Ana, California <br />Page 3 <br />August 8, 2014 <br />60A-208 <br />