Rental Adu Income Certification Form
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1
2RENTAL ADU INCOME CERTIFICATION FORM
Property Name: _______________________________________________________________________
Bldg. No./Unit No._____________________________________________________________________
I/We the undersigned certify that:
This Income Certification is being delivered in connection with the undersigned's application for ccupancy.
PART I - OCCUPANTS
NEW
_______ RECERTIFICATION __________/DATE LAST CERTIFIED __________________
Family
Name
Relationship
Age
Full-Time Student
Member
to Applicant
(Yes or No)
1 ____________________________________________________________________________________
2 ____________________________________________________________________________________
3 ____________________________________________________________________________________
4 ____________________________________________________________________________________
5 ____________________________________________________________________________________
6 ____________________________________________________________________________________
It is the responsibility of the individual or household to demonstrate eligibility under the requirements of the ADU Program. In order
to verify that an individual or household satisfies these requirements, FCRHA requires the landlord to obtain third party verification of
income. Such documentation includes, but is not limited to, copies of Federal and State income Tax Returns, W-2 forms and copies of
paychecks.
The maximum permitted income will be determined the gross income received annually from all sources by all wage earners over 18
years of age (who are not full-time students) in a family or household unit. Sources of income include, but are not necessarily limited
to, the following:
Yes / No
____/____
1.
wages and salary (full and part-time employment)
____/____
2.
child support
____/____
3.
alimony
____/____
4.
interest on savings and checking accounts
____/____
5.
dividends from stocks, bonds, and certificates of deposit
____/____
6.
social security benefits
____/____
7.
VA benefits
____/____
8.
overtime, commissions, tips and bonus payments
____/____
9.
unemployment insurance
____/____
10. pension/retirement payments
____/____
11. disability benefits
____/____
12. any other annuities or stipends received
____/____
13. income from real estate investments
____/____
14. income from a business or partnership owned, associated with or operated by a member of the household.
____/____
15. regular gifts or contributions from persons not residing in the dwelling as long as there is a documented two year
history.
____/____
16. net income from business operations, exclusive of amortization of capital indebtedness;
based on straight line
method is an acceptable expense. Three years federal tax returns
are required to document such income.
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