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1 <br />TENANT INCOME CERTIFICATION <br />Initial Certification Recertification Other ____________ <br />Effective Date: _____________________ <br />Move-In Date: ______________________ <br />(MM-DD-YYYY) <br />PART I - DEVELOPMENT DATA <br /> County: _______________ TCAC#: BIN#: <br /> If applicable, CDLAC#: <br />Property Name: <br />Address: <br />Unit Number: # Bedrooms: Square Footage: ___________ <br />PART II. HOUSEHOLD COMPOSITION <br />Vacant (Check if unit was vacant on December 31 of the Effective Date Year) <br /> HH <br />Mbr # Last Name First Name <br />Middle <br />Initial <br />Relationship to Head <br />of Household <br />Date of Birth <br />(MM/DD/YYYY) <br />Student Status <br />(Check One) <br />Last 4 digits of <br />Social Security # <br />1 HEAD <br />2 <br />3 <br />4 <br />5 <br />6 <br />7 <br />PART III. GROSS ANNUAL INCOME (USE ANNUAL AMOUNTS) <br />HH <br />Mbr # <br />(A) <br />Employment or Wages <br />(B) <br />Soc. Security/Pensions <br />(C) <br />Public Assistance <br />(D) <br />Other Income <br />TOTALS $ $ $ $ <br />Add totals from (A) through (D), above TOTAL INCOME (E): $ <br />PART IV. INCOME FROM ASSETS <br />HH <br /> Mbr # <br />(F) <br />Type of Asset <br />(G) <br />C/I <br />(H) <br />Cash Value of Asset <br />(I) <br />Annual Income from Asset <br />TOTALS: $ $ <br />Enter Column (H) Total Passbook Rate <br />If over $5000 $_____________ X 0.06% = (J) Imputed Income $ <br />Enter the greater 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 II acceptable verification of <br />current anticipated annual income. I/we agree to notify the landlord immediately upon any member of the household moving out of the unit or any new member <br />moving in. I/we agree to notify the landlord immediately upon any member becoming a full time student. <br />Under penalties of 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 herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination of <br />the lease agreement. <br />Signature (Date) Signature (Date) <br />Signature (Date) Signature <br />FT/PT/NA <br />FT/PT/NA <br />FT/PT/NA <br />FT/PT/NA <br />FT/PT/NA <br />FT/PT/NA <br />FT/PT/NA <br />(Date) <br />Tenant Income Certification (April 2021) <br />EXHIBIT 5