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Exhibit "C" <br /> 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 Total <br /> 1. Gross amount, before payroll deductions of $ $ $ <br /> wages, salaries, overtime pay, commissions, <br /> fees, tips and bonuses <br /> 2. Net income from business $ $ $ <br /> 3. Social security, annuities, insurance policies, $ $ $ <br /> pension/retirement funds, disability or <br /> death benefits received periodically <br /> 4. Payment in lieu of earnings, such as $ $ $ <br /> unemployment, disability compensation, <br /> worker's compensation and severance pay <br /> 5. Public assistance, welfare payments $ $ $ <br /> 6. Alimony, child support, other periodic $ $ $ <br /> allowances <br /> 7. 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 /> 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 Page 1 <br /> Rental Residential Development June 3,2025 <br />