TENANT INCOME SELF-CERTIFICATION
INSTRUCTIONS: All household members 18 or older (or if under 18 and qualified as Head, Co-Head, or Spouse) must complete a separate Tenant Self-Certification form. When completing this form, give detailed information such as:
a) name, address & phone number of employer;
b) hourly rate AND average number of hours worked in a week;
c) average GROSS (before taxes) income per pay period AND frequency of pay period (monthly, twice per month, every two weeks, weekly, etc.)
d) if employment is seasonal, provide total GROSS (before taxes) income and include number of weeks or months worked per year.
e) if NOT employed, provide other sources of income: Social Security, Disability or SSI payments, Child Support, TANF, Family or other cash assistance received on a regular basis (provide length of time cash assistance is anticipated). Provide name of source of other income. Food stamps are not considered income, BUT PLEASE list the amount received as it is considered when reviewing total ability to pay for living expenses.
f) provide specific information concerning ALL ASSETS listed on the Tenant Questionnaire that is a part of the self-certification process. Include assets of children.
g) if income listed does not cover anticipated expenses for rent, utilities and other living expenses, please provide information on how these expenses will be paid. Management may not complete this form.
INCOME & ASSETS: Please detail all current forms of income for the above resident. Follow the instructions shown above: [example: I work 40 hrs a week @ $10.00 an hour for XXXX company; or I receive $400.00 a month from Social Security or SSI; or $225.00 from TANF; or $315.00 a month from food stamps; or $100.00 a month from my parents; or $8.00 a year from my savings interest, etc.]
ᕞᛖᡎᧆᬾᭀᭂㆲ㌪㒢㘚㘜㘞㥴㥶㫆÷÷÷ï÷÷��
NO INCOME: Please provide information below on why you have no income, and how you will pay for living expenses (rent, utilities, food, etc). If you receive rent assistance (Section 8, Shelter Plus Care, Medicaid, etc.) then you may submit a statement from the agency providing rent or other cash assistance.
CERTIFICATION: I certify that I am the person identified as Resident above. Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. The undersigned further understand(s) that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination of a lease agreement.
Signature of Resident / Tenant Date