Income Certification - Texas
INCOME CERTIFICATION
HOUSEHOLD CERTIFICATION & SIGNATURES
The information on this form will be used to determine ma ximum income eligibility. I/we have provided for each person(s) set forth in Part II acceptable verification of
current anticipated annual income. I/we agree to notify the landlord immediately upon any me mber of the household moving out o f the unit or any new member moving
in. I/we agree to notify the landlord imm e diately upon any member becoming a full time student.
Under penalties of perjury, I/we certify that the information presented in this Certification is true and accurate to the best of my/our knowledge and belief. The
undersigned further understands that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in the
termination of the lease agreement.
Signature (Date) Signature (Date)
Signature (Date) Signature (Date)
- Income Certification (Revised January 2006)
Initial Certification Recertification Other* _________
Effective Date:
Move-in Date:
(MM/DD/YYYY)
*Transfer from Unit:
PART I – DEVELOPMENT DATA
Property Name: County: Unit Number: # Bedrooms:
PART II. HOUSEHOLD COMPOSITION
HH
Mbr #
Last Name
First Name & Middle
Initial
Relationship to Head
of Household
Date of Birth
(MM/DD/YYYY)
F/T Student
(Y or N)
Social Security
or Alien Reg. No.
1 HEAD
2
3
4
5
PART III. GROSS ANNUAL INCOME (USE ANNUAL AMOUNTS)
HH
Mbr #
(A)
Employment or Wages
(B)
Soc. Security/Pensions
(C)
Public Assistance
(D)
Other Income
TOTALS $ $ $ $
Add totals from (A) through (D) above TOTAL INCOME (E):
$
PART IV. INCOME FROM ASSETS
HH
Mbr #
(F)
Type of Asset
(G)
C/I
(H)
Cash Value of Asset
(I)
Annual Income from Asset
TOTALS: $ $
Enter Column (H) Total Passbook Rate
If over $5000 $_____________ X .06% = (J) Imputed Income $
Enter the greater of the total of column I, or J: imputed income TOTAL INCOME FROM ASSETS (K)
$
(L) Total Annual Household Income from all Sources [Add (E) + (K)]
$
PART V. DETERMINATION OF INCOME ELIGIBILITY
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