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55394.00101\43724951.1 <br /> <br /> <br />Page 65 <br />Exhibit E <br /> <br /> INCOME VERIFICATION FORM <br />Monthly Gross Income * <br /> <br />List All Sources of Income of All Household Members Living in the Affordable Unit <br /> <br />Part 1: Earned Income <br /> <br /> Head of <br />Household <br />Other <br />Household <br />Members Total <br />1. Gross wages, before payroll deductions and <br />including overtime pay, commissions, fees, tips <br />and bonuses. <br />$ $ $ <br />2. Net income from self employment, independent <br />contractor work or a business. <br />$ $ $ <br />3. Social security and any payments from annuities, <br />insurance policies, pension/retirement funds, <br />disability or death benefits received periodically. <br />$ $ $ <br />4. Payment in lieu of earnings, such as <br />unemployment, disability compensation, worker’s <br />compensation and severance pay. <br />$ $ $ <br />5. Public assistance, welfare payments $ $ $ <br />6. Alimony, child support, other periodic allowances $ $ $ <br />7. Regular pay, special pay and allowances of <br />members of the Armed Forces <br />$ $ $ <br />8. Other $ $ $ <br /> <br />Subtotal: Monthly Earned Income $ <br /> <br />Total Monthly Earned Income x 12 = $_______________ Total Annual Household Gross Earned Income <br /> <br />INCOME VERIFICATION FORM <br />Monthly Gross Income * <br />  <br />  <br />City Council 19 – 78 6/3/2025