Household Eligibility Questionnaire Page 1 of 4

Household Eligibility Questionnaire Page 1 of 4

HOUSEHOLD ELIGIBILITY QUESTIONNAIRE

Project Name:
Unit Number: / Number of Bedrooms:

List all occupants in the unit, their relationship to the head of household (if any), ages and whether they are students (for this purpose a student is anyone who has been or will be a full or part-time student at an educational institution with regular facilities and students during 5 months of the year this Application is submitted, other than correspondence school).

Household Member / Relationship / SS Number / Age / Birthdate / Full-time Student ** / Part-time
Student
Yes No / Yes No
Yes No / Yes No
Yes No / Yes No
Yes No / Yes No
Yes No / Yes No

** Full time student within the current calendar year (January – December)

Are any household changes expected in the next 12 months? Yes No

If yes, please explain: ______

Are any changes in student status expected in the next 12 months? Yes No

If yes, please explain: ______

Eligibility:
I have a household member who is absent from the home due to:
Employment / Yes No
Military Service / Yes No
Placement in foster care / Yes No
Temporarily in nursing home or hospital / Yes No
Permanently confined to nursing home / Yes No
Away at school / Yes No
Other:
I have a live-in attendant / Yes No

Are you or anyone else who will be living in your household subject to registration as a sexual offender and/or sexual predator? Yes No. If yes, please explain:

______

To be clear in regard to government definitions, we will now go over a checklist of household income and assets. Please answer yes or no to the following and if yes, provide the amounts. Do you or any member of your household have income from:

Employment / Yes / No / $
2nd Employment / Yes / No / $
Overtime/Shift Pay / Yes / No / $
Commissions, Tips, or Bonuses / Yes / No / $
Cash Pay / Yes / No / $
Seasonal/Sporadic Income / Yes / No / $
Military Pay / Yes / No / $
Net Income from Business / Yes / No / $
Unemployment / Yes / No / $
Workman’s Compensation / Yes / No / $
Social Security / Yes / No / $
SSI / Yes / No / $
Veteran’s Benefits / Yes / No / $
Retirement Account Payments / Yes / No / $
Pensions/Annuity / Yes / No / $
Disability Benefits / Yes / No / $
Severance Pay / Yes / No / $
TANF/Public Assistance / Yes / No / $
Child Support / Yes / No / $
Spousal Support / Yes / No / $
Non-cash Contributions / Yes / No / $
Gift Income / Yes / No / $
Real Estate Rental Income / Yes / No / $
Student Financial Aid / Yes / No / $
Other income / Yes / No / $

For each type of income that your household receives, give the source of the income and the

amount of income that can be expected from that source during the next 12 months.

Family Member / Source/Type of Income / Estimated Annual Income

For elderly or disabled only: Do you or any member of your household expect to incur any out-of-pocket medical expenses that would not be covered by insurance? Yes No

Are you enrolled in a Medicare Prescription Drug Plan? Yes No

Do you or a family member have any of the following assets?

Cash on hand / Yes / No
Direct Deposit Debit Card / Yes / No
Checking Accounts / Yes / No
Savings Accounts / Yes / No
Certificates of Deposit / Yes / No
IRA/Keogh Accounts / Yes / No
Other Retirement Funds / Yes / No
Stocks or Bonds / Yes / No
Treasury Bills / Yes / No
Mutual Funds / Yes / No
Trust Accounts / Yes / No
Annuities, revocable or non-revocable trust / Yes / No
Whole or Universal Life Insurance / Yes / No
Real Estate/Home/Property Equity / Yes / No
Money Market Account / Yes / No
Assets held in another state or foreign country / Yes / No

Have you or any other members of the household received any lump sum payments, such as:

Inheritance / Yes / No
Lottery winnings / Yes / No
Insurance settlements / Yes / No
Other:

List all checking and savings accounts (including debit cards, direct deposit account, IRAs, Keogh accounts and Certificates of Deposit) of all household members.

Description of Asset / Financial Institution / Account Number / Estimated Balance

List the value of any cash on hand, assets held in safety deposit boxes, stocks, bonds, trusts, whole life insurance policies, pension contributions, etc. or other assets:

Do you pay childcare for children 12 and under which enables you or another family member to work or to go school? Yes No

Do you have disability expenses that are not paid for by an outside source? Yes No

If yes, is this service necessary to enable a household member (including the member with a disability) to

be employed? Yes No

Do you have attendant care expenses? Yes No

If yes, is this service necessary to enable a household member (including the member with a disability) to

be employed? Yes No

Do you or any household members have any assets that are held jointly with another person? Yes No

Did you have any assets in the last two years not listed above? Yes No

If yes, did you dispose of the asset for less than fair market value? Yes No

[This means that the assets were either given away or sold for less than market value)

If yes, what were the assets, the market value at the time of disposition, the amount received and the date you disposed of the assets?

Any assets disposed of for less than fair market value in the two years before the effective date of this application will be counted as assets if the difference between the market value and the amount received exceeds $1,000.

RESIDENTS STATEMENT: I understand that the above information is being collected to determine my eligibility for residency. I authorize the Owner/Manager to verify all information provided on this Recertification Questionnaire and my signature is consent to obtain such verification. I certify that I have revealed all assets currently held or previously disposed of and that I have no other assets than those listed on this form (other than personal property). I further certify that the statements made in this Recertification Questionnaire are true and complete to the best of my knowledge and belief and are aware that false statements are punishable under Federal law by fine or imprisonment or both.

Signature of Head: ______Date: ______

Signature of Spouse/Co-Tenant: ______Date: ______

Other Household Members 18 or Older: ______Date: ______

______Date: ______

______Date: ______

______Date: ______

Phone Number for follow-up contact: ______

WARNING: Section 1001 of Title 18 U.S. Code makes it a criminal offense to willfully falsify a material fact or make a false statement to any matter within the jurisdiction of a federal agency.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1)mail: U.S. Department of Agriculture (2) fax: (202) 690-7442; or

Office of the Assistant Secretary for Civil Rights

1400 Independence Avenue, SW (3) email:

Washington, D.C. 20250-9410;

USDA is an equal opportunity provider, employer, and lender.

TM Associates Management, Inc. 0316