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TENANT 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 /> Total <br /> Other Adult Household <br /> Head of Household Investment <br /> Household Members Income <br /> 1. 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) $ $ $ <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 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 Page 3 <br /> Santa Ana, California August8,2014 <br />