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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 />Household Members Total <br />1. Gross wages, before payroll deductions and $ $ $ <br />including overtime pay, commissions, fees, tips <br />and bonuses. <br />2. <br />Net income from self employment, independent <br />$ <br />$ <br />$ <br />contractor work or a business. <br />3. <br />Social security and any payments from annuities, <br />$ <br />$ <br />$ <br />insurance policies, pension/retirement funds, <br />disability or death benefits received periodically. <br />$ <br />4. <br />Payment in lieu of earnings, such as <br />$ <br />$ <br />unemployment, disability compensation, worker's <br />compensation and severance pay. <br />Public assistance, welfare payments <br />Alimony, child support, other periodic allowances <br />5. <br />$ <br />$ <br />$ <br />6. <br />$ <br />$ <br />$ <br />7. Regular pay, special pay and allowances of <br />$ <br />$ <br />$ <br />members of the Armed Forces <br />8. Other <br />Subtotal: Monthly Earned Income <br />$ I$ <br />$ <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 />55394.001 01\43724951 .1 <br />