Supplement To Application For Federally Assisted Housing Template Page 2
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10Sources of Income Verification
Please turn in recent documentation for all sources of income, including, but not limited to:
Employment-60 days of pay stubs no more than 30 days old Unemployment TANF Award Letter
Disability Income from a Job
Worker’s Compensation
Military Pay Odd/Seasonal Jobs
Military Pension
Retirement Pension SNAP/ Food Stamps Award Letter
Child Support-Divorce Decree or Print Out (dating back at least 1 year)
Social Security-ANY form-including: SS, SSDI, SSI, SS Widows, SS survivors, ANY back-pay
Prior year’s tax records (Only if self-employed, including tax forms filed, W-2’s, etc.)
Student Aid-ANY form, including but not limited to: Grants, Loans, Scholarships, Fellowships, Work Study,
Internships, and Apprenticeships
Self-Employment: we will need a signed and dated statement of self-certification
Trustee Assistance: we will need a statement on the trustee’s letterhead
Energy Assistance: we will need the SCCAP worksheet, or a statement on SCCAP letterhead
Assistance from churches/other agencies: we will need a statement on letterhead
Lottery/Gambling winnings- any form of Hoosier Lottery, any other State Lottery, Pull-tabs, Scratch Offs, Bingo
winnings
Selling/Reselling/Salvaging Items including but not limited to: Plasma, Aluminum/Steel Cans, Scrap Metals,
Yard/Garage sales, Card Collections (Baseball, Basketball, Football, etc.), any type of Collection selling
For the following income types we will need a signed and dated statement that includes the phone number from the
person(s) giving the money:
Work for Cash
Baby Sitting
Money from family/friends
ANY other income that is not listed above MUST be reported on the application and documents supporting the
income must be brought in for verification.
Assets (must be a current statement dated within last 60 days)
Checking accounts Savings accounts Bonds IRAs Money Market accounts UTMA accounts
House CDs Stocks Mobile Home Trailer Land Investments Inheritance
ANY other assets
Children & Child Care
Proof of Custody/Guardianship (including court documentation or school records showing the child is registered
Signed statement from childcare provider
in school under the applicants address)
If you are expecting a child we will need proof of pregnancy or a signed doctor’s statement.
If you are handicapped/disabled or elderly (62 or over)
Medical insurance statement-must show how often premium is paid
Signed statements from doctors for your ongoing out-of-pocket expenses
Signed statements or print out from pharmacies for your out-of-pocket expenses
I understand if I fail to provide the required documentation or make false statements or misinterpretations on
my application, my application for the Public Housing program will be considered incomplete and therefore
will not be accepted without further notice.
HOH Signed: ___________________________________________ Date: ____________________
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