Form 056a - Anticipated Monthly Expense Questionnaire

Anticipated Monthly Expense Questionnaire

Name: ______________________________

Unit #: ____________

E-Mail: _____________________________

Phone #:_______________________

Living expenses continue even though you are not actively employed.

1. In the past twelve months, have you had any income from any source? ____Yes ____No

If yes, from where/who? ______________________________________________________________

2. Do you have any money in the bank, or put away somewhere? ____Yes ____No

If yes, where and how much? __________________________________________________________

3. Do you do any odd jobs like field work, or babysitting? ____Yes

____No

If yes, what and how much are you paid and how often? ____________________________________

4. Do your parents, relatives, children, friends, or any other person and/or agency outside of your

household provide assistance in guaranteeing your monthly household needs are met?

____Yes ____No If yes, who, what (how much), and how often: ___________________________

___________________________________________________________________________________

MONTHLY HOUSEHOLD EXPENSES

After each heading, please fill in the average monthly expense for each item.

Fill in each item whether or not the expense is paid by a household member or not.

Utilities

Laundry Supplies

Tobacco

*Form HUD 92458

$

$

$

Car Payment

Laundry Cleaning Expense

Clothing

$

$

$

Toiletries/Paper Products

Car Insurance

Diapers

$

Personal Hygiene Products

$

$

Gas/Travel

Phone Bill

Personal

*Gov’t Phone $26

Expense

$

$

Grooming

$

Rent

Medical

Satellite/Dish/Cable Bill

*HUD min TR $25

$

$

Expenses

$

TOTAL OF ANTICIPATED MONTHLY HOUSHEOLD EXPENSES

$__________

Please read: By my signature I certify that the information I have provided above is true and complete to

the best of my knowledge and belief. I understand that if I furnish false or incomplete information I can

be fined up to $10,000 or imprisoned up to five years, or lose the subsidy HUD pays and/or have my rent

increased.

I, _________________________________, state that __I am or that __ I am not currently employed on this date.

I acknowledge, and understand, that anytime my household support/income/assistance increases by $200

or more per month I must report it to management within 10 days of the date of the increase.

Signature: ___________________________________

Date: _________________

This Property does not discriminate on the basis of disability status in the admission or access to, or treatment or employment in, its federally assisted programs and activities.

Form 056a

2/2015