Form Ftb 9106 - Household Income Schedule
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1STATE OF CALIFORNIA
FRANCHISE TAX BOARD
HOMEOWNER AND RENTER ASSISTANCE PROGRAM
PO BOX 942886
SACRAMENTO CALIFORNIA 94286-0940
HOUSEHOLD INCOME SCHEDULE
Please complete this schedule and return it with our letter.
Household income includes the total of all amounts received by you, your spouse and other members of your household.
Household income does not include the income of minors, students, renters and, in the case of renter assistance
claimants, the income of the owners of the property.
Please list the name, relationship and age of the persons who lived in your home as their principal place of residence in all
or part of the year for which you claimed assistance. DO NOT list minors, renters, students or the property owners.
SPOUSE NAME
SPOUSE SOCIAL SECURITY NUMBER
AGE
OTHER MEMBERS OF HOUSEHOLD
NAME
RELATIONSHIP
AGE
CALENDAR YEAR INCOME
JANUARY 1 THROUGH
INCOME – INCLUDE THE INCOME OF YOU AND YOUR SPOUSE.
DECEMBER 31, ___________
MONTHLY
YEARLY
$
$
1 Social Security and/or Railroad Retirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 Interest and/or Dividends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3 Pensions and Annuities (and IRA distributions) _____________________________
4 SSI/SSP (Gold Checks) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5 Net Rental Income (attach schedule) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6 Net Business Income (attach schedule) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7 Capital Gains/Losses (attach schedule) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8 Other Income (including wages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
List source here _____________________________________________________
9 Income of Other Household Members. (Do not include income of minors,
students, renters, yourself or your spouse.)
List source here _____________________________________________________
$
$
10 Total Household Income (add lines 1 through 9) . . . . . . . . . . . . . . . . . . . . . . . . . .
11 Less Adjustments to Income (such as forfeited interest penalty, alimony that you
paid, contributions you made to certain retirement plans, amounts that you paid
for the self-employed health insurance deduction and/or self-employment tax
$
$
deduction) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
$
12 Total Household Income (subtract line 11 from line 10) . . . . . . . . . . . . . . . . . . . . .
YOUR SOCIAL SECURITY NUMBER
YOUR TELEPHONE NUMBER
(
)
—
SIGN HERE
DATE
FTB 9106 (REV 12-2005)
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Parent category: Financial