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<br />INCOME VERIFICATION FORM <br />Monthly Gross Income * <br />List All Sources of Income of All Household Members Living in the Affordable Unit <br />Part 1: Earned Income <br />Other <br />Head of Household <br />MembersHousehold Total <br />1.Gross wages, before payroll deductions and <br />including overtime pay, commissions, fees, tips <br />and bonuses. <br />$$$ <br />2. <br />3. <br />Net income from self employment, independent <br />contractor work or a business. <br />$ <br />$ <br />$ <br />$ <br />$ <br />$Social security and any payments from annuities, <br />insurance policies, pension/retirement funds, <br />disability or death benefits received periodically. <br />4.Payment in lieu of earnings, such as $$$ <br />unemployment, disability compensation, worker’s <br />compensation and severance pay. <br />5. <br />6. <br />7. <br />Public assistance, welfare payments $ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />Alimony, child support, other periodic allowances <br />Regular pay, special pay and allowances of <br />members of the Armed Forces <br />8.Other $$$ <br />$Subtotal: Monthly Earned Income <br />Total Monthly Earned Income x 12 = $_______________ Total Annual Household Gross Earned Income <br />INCOME VERIFICATION FORM <br />Monthly Gross Income * <br />Page 65 <br />Exhibit E <br />55394.00101\43423340.1 <br />  <br />  <br />City Council 24 – 77 4/15/2025