ANNUAL RECERTIFICATION QUESTIONNAIRE
Tenant name: ______unit: ______
address: ______phone: ______
Email address: ______Cell Phone: ______
Household Composition:
Tenant Name / Relationship / Date of Birth / Age / Student (y/n)Head
2
3
4
5
Additional household information: yes no
Are any household members temporarily absent?If yes, list the names: ______/ /
Are any household members permanently absent?
If yes, list the names: ______/ /
Are there any Foster Children or Foster Adults who are part of the household?
If yes, list the names: ______/ /
Are there any Live-In Care attendants who are part of the household?
If yes, list the names: ______/ /
Are any members of your household a full-time student, or planning to become a student within the next twelve months (full or part-time)?
If yes, list the names: ______/ /
Has the employment status of any household member(s) changed?
If yes, list the member name(s) and the type of change (include the employer’s name):
______/ /
Current employment information:
Employer’s NameStreet Address / City / State / Zip Code
Date Hired / Hourly Weekly Bi-Weekly Twice a month Monthly Yearly Other
Gross Salary $______ / Hours worked per week
Termination Date / Supervisor’s Name / Work Telephone # / Work Fax #
Additional employment:
Employer’s NameStreet Address / City / State / Zip Code
Date Hired / Hourly Weekly Bi-Weekly Twice a month Monthly Yearly Other
Gross Salary $______ / Hours worked per week
Termination Date / Supervisor’s Name / Work Telephone # / Work Fax #
IF CURRENTLY UNEMPLOYED, LIST PREVIOUS EMPLOYMENT
Employer’s NameStreet Address / City / State / Zip Code
Date Hired / Hourly Weekly Bi-Weekly Twice a month Monthly Yearly Other
Gross Salary $______ / Hours worked per week
Termination Date / Supervisor’s Name / Work Telephone # / Work Fax #
Source of income:
Is incomereceived from any of the following? Please mark “yes” or “no” for each source of income.
Employment IncomeCheck one / Amount Received / Frequency PaidBonusesYesNo / Income______ / Weekly Monthly Annually
TipsYesNo / Income______ / Weekly Monthly Annually
Commission /feesYesNo / Income______ / Weekly Monthly Annually
Overtime payYesNo / Income______ / Weekly Monthly Annually
Typical overtime worked throughout the year / Hourly Rate$______
Hours Worked______/ Week Pay Period Month
Occasional or seasonal overtime / Hourly Rate$______
Overtime Hours ______/ Week Pay Period Month
Workers compensation YesNo / Amount / Month $ ______
Unemployment YesNo / Amount / Month $ ______
1 ANNUAL RECERTIFICATION QUESTIONNAIRE 5/1/2010
ANNUAL RECERTIFICATION QUESTIONNAIRE
Please circle YES or NO for every item listed below. If you answer Yes, enter the amount received under the appropriate Household member’s name.
Does any Household Member have or expect to have: Head #2 #3 #4 #5
Checking Account (If yes, enter the balance) / Yes / No / $ / $ / $ / $ / $Savings Account / Yes / No / $ / $ / $ / $ / $
Cash on Hand / Yes / No / $ / $ / $ / $ / $
Certificate of Deposits / Yes / No / $ / $ / $ / $ / $
Company Retirement Acct. / Yes / No / $ / $ / $ / $ / $
IRA/Keogh Accounts / Yes / No / $ / $ / $ / $ / $
Life Insurance Policies / Yes / No / $ / $ / $ / $ / $
Money Market Funds / Yes / No / $ / $ / $ / $ / $
Pension Funds / Yes / No / $ / $ / $ / $ / $
Safe Deposit box, at home, etc. / Yes / No / $ / $ / $ / $ / $
Stocks and Bonds / Yes / No / $ / $ / $ / $ / $
Treasury Bills / Yes / No / $ / $ / $ / $ / $
Trust Accounts / Yes / No / $ / $ / $ / $ / $
If yes, is it irrevocable? / Yes / No
House/Real Estate / Yes / No / $ / $ / $ / $ / $
Rental Property / Yes / No / $ / $ / $ / $ / $
Coin collections, antique cars, stamps, jewelry or gems, or any other items held as an investment? (this does not include wedding rings and other personal jewelry) / Yes / No / $ / $ / $ / $ / $
Capital Gains / Yes / No / $ / $ / $ / $ / $
Inheritances / Yes / No / $ / $ / $ / $ / $
Insurance Settlements / Yes / No / $ / $ / $ / $ / $
Lottery or other Winnings / Yes / No / $ / $ / $ / $ / $
Social Security Disability Settlements / Yes / No / $ / $ / $ / $ / $
Unemployment Compensation Settlement / Yes / No / $ / $ / $ / $ / $
Veteran’s Disability Settlements / Yes / No / $ / $ / $ / $ / $
Worker’s Comp Settlements / Yes / No / $ / $ / $ / $ / $
Wages, Salary, thru Employment / Yes / No / $ / $ / $ / $ / $
Does any member work for someone who pays them cash? / Yes / No / $ / $ / $ / $ / $
Alimony / Yes / No / $ / $ / $ / $ / $
Child Support / Yes / No / $ / $ / $ / $ / $
Public Assistance or AFDC / Yes / No / $ / $ / $ / $ / $
Regular pay as a member of the armed forces / Yes / No / $ / $ / $ / $ / $
Self Employment / Yes / No / $ / $ / $ / $ / $
Social Security/SSI / Yes / No / $ / $ / $ / $ / $
Unemployment benefits or severance pay / Yes / No / $ / $ / $ / $ / $
Veteran’s benefits / Yes / No / $ / $ / $ / $ / $
Worker’s Compensation benefits / Yes / No / $ / $ / $ / $ / $
Annuities Income / Yes / No / $ / $ / $ / $ / $
Disability or Death Benefits / Yes / No / $ / $ / $ / $ / $
Retirement Income / Yes / No / $ / $ / $ / $ / $
Regularly Recurring monetary gifts from individuals not living in the unit or organizations such as churches (include rent, utilities, groceries, etc) / Yes / No / $ / $ / $ / $ / $
yes no
Have you disposed of any assets for less than Fair Market Value in the past two years? (State if the sale was due to foreclosure, bankruptcy or divorce, answer No)If yes, list the asset(s) you disposed of, the date of disposition, the fair market value and the amount received:
______
______
______
yes no
Are any of the assets listed above held jointly with another person?If yes, list the assets: ______
______
Household Certification:
I/We certify that the information presented on this form is true and complete to the best of my/our knowledge and belief. I/We understand that it is my/our responsibility to report to management changes in income, assets, expenses and/or family composition whenever they occur. I/we acknowledge that I have been informed that this information is being obtained to verify the household’songoing eligibility and compliance with the Low-Income Housing Tax Credit Program as regulated by Section 42 of the Internal Revenue Code. Submittal of false statements is punishable under Federal law and will lead to cancellation of this application or termination of tenancy.