Asset Certification/disposed Of Assets Template

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UNDER $5,000 ASSET CERTIFICATION/DISPOSED OF ASSETS
For households whose combined net assets do not exceed $5,000.
Complete only one form per household; include assets of children.
Household Name:
Unit No:
Development Name:
City:
Complete all that apply for 1 through 4:
1.
I/we do not have any assets at this time.
OR
2.
My/our assets include:
(A)
(B)
(A*B)
(A)
(B)
(A*B)
Cash
Int.
Annual
Cash
Int.
Annual
Source
Value*
Rate
Income
Source
Value*
Rate
Income
Savings Account
________
_____
$________
Checking Account
$________
_____
$________
Cash on Hand
________
_____
$________
Safety Deposit Box
$________
_____
$________
Certificates of Deposit
________
_____
$________
Money Market Funds
$________
_____
$________
Stocks
________
_____
$________
Bonds
$________
_____
$________
IRA Accounts
________
_____
$________
401K Accounts
$________
_____
$________
Keogh Accounts
________
_____
$________
Trust Funds
$________
_____
$________
Equity in Real Estate
________
_____
$________
Land Contracts
$________
_____
$________
Lump Sum Receipts
________
_____
$________
Capital Investments
$________
_____
$________
Life Insurance Policies (excluding Term)
$________
_____
$________
Other Retirement/Pension Funds not named above: ______________________________
$________
_____
$________
Personal property held as an investment**: ____________________________________
$________
_____
$________
Other (list): ____________________________________________________________
$________
_____
$________
PLEASE NOTE: If ANY assets are indicated, each line item under column (A) must be completed. If you do not have a particular asset, you may indicate “N/A”
or draw a line in column (A). Certain funds (e.g., Retirement, Pension, Trust) may or may not be (fully) accessible to you. Include only those amounts which are
accessible.
*Cash value is defined as market value minus the cost of converting the asset to cash, such as broker’s fees, settlement costs, outstanding loans, early withdrawal
penalties, etc.
**Personal property held as an investment may include, but is not limited to, gem or coin collections, art, antique cars, etc. Do not include necessary personal property
such as, but not necessarily limited to, household furniture, daily-use autos, clothing, assets of an active business, or special equipment for use by the disabled.
Within the past two (2) years, I/we have sold or given away assets (including cash, real estate, etc) for more than
3.
$1,000 below their fair market value (FMV). Those amounts* are included above and are equal to a total of:
$
(*the difference between FMV and the amount received, for each asset on which this occurred).
I/we have not sold or given away assets (including cash, real estate, etc.) for less than fair market value during the past two (2)
4.
years.
The net family assets (as defined in 24 CFR 813.102) above do not exceed $5,000 and the annual income from the net family
assets is $
. This amount is included in total gross annual income.
Under penalty of perjury, I/we certify that the information presented in this certification is true and accurate to the best of my/our
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.
___________________________ _________________
Applicant/Tenant
Date
Applicant/Tenant
Date
WARNING: Section 1001 of Title 18 U.S. Code makes it a criminal offense to willfully falsify a material fact or make a false
statement in any matter within the jurisdiction of a federal agency.
UNDER $5,000 ASSET CERTIFICATION/DISPOSED OF ASSETS
Revision 4/8/2016

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