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EXHIBIT “B” <br /> Income Verification Form Page 3 <br />Santa Ana, California <br />INCOME VERIFICATION FORM <br />Monthly Gross Income * <br />List All Sources of Income of All Household Members Living in the Inclusionary Unit <br />Part 2: Investment Income <br />Head of <br />Household <br />Other Adult <br />Household <br />Members <br />Total <br />Household <br />Investment <br />Income <br />1. Interest paid on Bank and Savings accounts $ $ $ <br />2. Dividends and other payments from stocks and <br />bonds <br />$ $ $ <br />3. Income from real property (i.e. rental property) $ $ $ <br />4. Other (describe) $ $ $ <br />Subtotal: Monthly Investment Income: $ <br />Total Monthly Investment Income x 12 = $_______________ Total Annual Household Investment Income <br />*Note: The following items are not considered income: casual or sporadic gifts; amounts specifically for or in <br />reimbursement of medical expenses; lump 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 act ually 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 />  <br />  <br />City Council 23 – 113 10/17/2023