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TENANT INCOME CERTIFICATION QUESTIONNAIRE <br />One Form per Adult Member of the Household <br />NAME: TELEPHONE NUMBER: <br />_______________________________________________________ ________________________ <br /> Initial Certification BIN #_________________________ <br /> Re-certification <br /> Other Unit #_________________________ <br />INCOME INFORMATION <br /> YES NO MONTHLY GROSS INCOME <br />1. I am self-employed. (List nature of self employment) <br />_______________________________________________ <br />(use net income from self-employment only) <br />$_________________ <br /> 2. I have a job and receive wages, salary, overtime pay, commissions, fees, tips, bonuses, and/or <br />other compensation: List the businesses and/or companies that pay you: <br /> Name of Employer <br /> <br /> 1)__________________________________________ <br /> <br /> 2)__________________________________________ <br /> <br /> 3)__________________________________________ <br /> <br /> <br /> <br /> <br />$_________________ <br /> <br />$_________________ <br /> <br />$_________________ <br />3. I receive cash contributions of gifts including rent or utility payments, on an ongoing basis from <br />persons not living with me. <br /> <br />$_________________ <br />4. I receive unemployment benefits. <br />$_________________ <br />5. I receive Veteran’s Administration, GI Bill, or National Guard/Military benefits/income. <br />$_________________ <br />6. I receive periodic social security payments. <br />$_________________ <br />7. The household receives unearned income from family members age 17 or under (example: <br />Social Security, Trust Fund disbursements, etc.). <br /> <br />$_________________ <br />8. I receive Supplemental Security Income (SSI). <br />$_________________ <br />9. I receive disability or death benefits other than Social Security. <br />$_________________ <br />10. I receive Public Assistance Income (examples: TANF, AFDC) <br />$_________________ <br />11. <br /> <br /> <br /> <br />I am entitled to receive child support payments. <br />I am currently receiving child support payments. <br /> If yes, from how many persons do you receive support? ________ <br />I am currently making efforts to collect child support owed to me. List efforts being made to <br />collect child support: <br /> <br /> <br /> <br /> <br />$_________________ <br />$_________________ <br /> <br />12. I receive alimony/spousal support payments <br />$__________________ <br />13. <br /> <br />I receive periodic payments from trusts, annuities, inheritance, retirement funds or pensions, <br />insurance policies, or lottery winnings. <br /> If yes, list sources: <br /> 1)_____________________________________ <br /> <br />$__________________ <br />$__________________ <br />14. I receive income from real or personal property. (use net earned income) <br />$__________________ <br />15. Student financial aid (public or private, not including student loans) <br />Subtract cost of tuition from Aid received <br />*For Households receiving Section 8 Assistance Only <br /> <br />$__________________ <br /> <br />ASSET INFORMATION <br /> YES NO INTEREST RATE CASH VALUE <br />16. I have a checking account(s). <br /> If yes, list bank(s) <br /> 1)_____________________________ <br /> 2)_____________________________ <br /> <br /> <br />_______% <br />_______% <br /> <br /> <br />$____________ <br />$____________ <br />Tenant Income Questionnaire (July 2018) <br />EXHIBIT 5