Form Cp-4 - Application For Community Preservaton Act Exemption - Low Income Person Page 3
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4E. HOUSEHOLD GROSS INCOME DURING PRECEDING CALENDAR YEAR. List income received from all sources for each member of household 18 and
older and not full time student during calendar year before January 1. Please list members in same order as shown in Schedule C above. Copies of federal
and state income tax returns may be requested to verify income reported for each household member.
Applicant
Member 1
Member 2
Member 3
Name
Name
Name
Name
TYPE OF INCOME
____________________
_____________________
______________________
______________________
Wages, salaries, other compensation
$
$
$
$
Social Security
Other pension/retirement benefits
Interest/dividends
Rental income
Net profits from business or profession
Capital gains
Alimony
Child support
Public assistance
Unemployment compensation
Disability compensation
Other (specify):
TOTAL GROSS INCOME - MEMBERS
$
$
$
$
TOTAL GROSS INCOME -
$
HOUSEHOLD
Continue list on attachment, in same format, as necessary.
F. CO-OWNERS’ HOUSEHOLD GROSS INCOME DURING PRECEDING CALENDAR YEAR.
Does Schedule E above include the gross income of all co-owners of the property as of January 1, _____? Yes
No
If no, a Schedule C, D and E must be attached for each co-owner not included.
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