Declaration Of Household Income (For Major Long-Term Repair Petitions Only) Form

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CITY OF BERKELEY
RENT STABILIZATION BOARD
2125 Milvia Street, Berkeley, CA 94704
TEL: (510) 981-7368 (981-RENT) TDD: (510) 981-6903 FAX: (510) 981-4940
E-MAIL: rent@ci.berkeley.ca.us INTERNET:
DECLARATION OF HOUSEHOLD INCOME
(for Major Long-term Repair petitions only)
Note: This information is confidential and may be viewed only by rent board staff and your landlord.
You are not required to send a copy of the Declaration of Household Income to your landlord; your landlord
may review the completed form in our files only after signing a confidentiality agreement.
Property address: _____________________________________________________Unit: _____________
Number of people in household: ______ Household annual gross income: $________________________
Is anyone in the household over age 62? Yes _____ No _____
Source of Income (attach documentation to verify the amounts reported.)
Income Amount
Wages, salaries and other monetary compensation for each wage earner in the
household over age 18: Attach pay stubs or verification letter from employer.
Business Income: Attach copies of account ledgers, tax returns or similar
documents.
Interest, dividends and royalties: Attach copies of checks or bank or stock
statements.
Social Security, retirement funds, pensions and annuities: Attach copies of checks or
other verification.
Unemployment, workers’ compensation or other payment in lieu of earnings: Attach
copies of checks or other verification.
Social Security Disability Income (SSDI), Supplemental Security Income (SSI) or
Welfare Assistance: Attach copies of checks or other verification.
THIS FORM MUST BE SIGNED BY ALL ADULT MEMBERS OF THE HOUSEHOLD
I declare under penalty of perjury of the laws of the State of California that the above amounts constitute the
total annual gross income received by all members of the household over age 18.
1.
Signature _____________________________________________ Date ______________________
Printed Name _____________________________________________________________________
2.
Signature _____________________________________________ Date ______________________
Printed Name _____________________________________________________________________
3.
Signature _____________________________________________ Date ______________________
Printed Name _____________________________________________________________________
4.
Signature _____________________________________________ Date ______________________
Printed Name _____________________________________________________________________
G:\RAFORMS\HEARFRMS\DECHHINC MAJREP.doc
10/28/05

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