Rental Application - Usda/hud Properties Only Page 5
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10USDA/HUD HOUSING APPLICATION
BENEFITS:
Please list the total benefit income of all members of the household. If a divorce decree or separation
agreement exists but payments are not received, list the amount court ordered by the document.
Benefit Type
Amount
Per
Household Member
Received
Receiving Benefit
Social Security (Adult)
Y N
Social Security (Child)
Y N
SSI (Adult)
Y N
SSI (Child)
Y N
Disability or Death Benefits
Y N
Public Assistance (AFDC, TANF)
Y N
Alimony
Y N
Child Support
Y N
OTHER INCOME:
Does any member of the household have income from any of the following? If yes, state the amount,
frequency, and the household member receiving the income.
Income Type
Amount
Per
Household Member
Received
Receiving Benefit
Income from Self‐Owed Business
Y N
Recurring Cash Contributions or Gifts
Y N
including Rent or Utility Payments
Worker’s Compensation
Y N
Unemployment Benefits
Y N
Severance Pay
Y N
Payments from Insurance Policies
Y N
Retirement Benefits
Y N
Pension Benefits
Y N
Educational Grants/Scholarships
Y N
Veteran’s Administration Benefits
Y N
Military Reserves/National Guard
Y N
GI Bill Benefits
Y N
Periodic Payments from Lottery
Y N
Winnings
Member of Indian Tribe receiving
Y N
gaming payments
Any Other Income: _____________
Y N
Page 5 of 10
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