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TENANT INCOME VERIFICATION FORM <br />2021 AFFORDABLE HOUSING OPPORTUNITY AND CREATION ORDINANCE <br />CITY OF SANTA ANA <br />Table 1: Annual Household Gross Earned Income 1 <br />List All Sources of Earned Income for all Adult Household Members Living in the Inclusionary Unit <br />Other Adult <br />Head of Household <br />Household Members <br />Total <br />1. Gross amount, before payroll deductions of $--$- <br />$ <br />wages, salaries, overtime pay, commissions, <br />fees, tips and bonuses <br />2. Net income from business $ $ <br />$ <br />3. Social security, annuities, insurance policies, $ $ <br />$ <br />pension/retirement funds, disability or <br />death benefits received periodically <br />4. Payment in lieu of earnings, such as $ $ <br />$ <br />unemployment, disability compensation, <br />worker's compensation and severance pay <br />5. Public assistance, welfare payments $ $ <br />$ <br />6. Alimony, child support, other periodic $ $ <br />$ <br />allowances <br />7. Regular pay, special pay and allowances of $ $ <br />$ <br />members of the Armed Forces <br />8. Other $ $ <br />$ <br />Subtotal: Monthly Earned Income <br />$ <br />Total Monthly Earned Income x 12 = $ Total Annual Household Gross Earned Income <br />1 The following items are not considered income: casual or sporadic gifts; amounts specifically for or in reimbursement of <br />medical expenses; lump sum payments such as inheritances, insurance payments, capital gains and settlement for personal <br />or property losses; educational scholarships paid directly to the student or educational institution; special pay to a <br />serviceman head of family away from home and under hostile fire; relocation payments under federal, state or local law; <br />foster child care payments; value of coupon allotments for purpose of food under Food Stamp Act of 1964 which is in <br />excess of amount actually charged the eligible household; payments received pursuant to participation in the following <br />programs: VISTA, Service Learning Programs, and Special Volunteer Programs, SCORE, ACE, Retired Senior Volunteer <br />Program, Foster Grandparent Program, Older American Community Services Program, and National Volunteer Program to <br />Assist Small Business Experience. <br />Administrative Procedures Manual <br />Rental Residential Development Page 1 <br />April 27, 2023 <br />