Ethnicity: 1 = Hispanic 2 = Non-Hispanic

Property Name: ______
Unit: ______
Unit Bedroom Size: Contract Rent: $
HUD Section8 HUD Section 8/236 HUD/USDA(515/Section8) USDA-RD/RA BMIR/Market
As applicable:
Housing Credit ______%HTC Risk Share HOME Special Needs Families with Children
Effective Date: Move-in Program Change A/R I/R/Unscheduled Assign RA
Section 1 Household:
Last Name / First Name / M
I / Rel / DOB / Sex / SSN / E/H / Stu
dent / Citizen / Race / Eth
H
2
3
4
5
6
7
8
9
10

Ethnicity: 1 = Hispanic 2 = Non-Hispanic

Race: I = American Indian or Alaskan NativeA = Asian B = Black or African American

H = Native Hawaiian or Other Pacific Islander W = White O = Other

Section 2- INCOME (include exempt income for reference):
MBR / Type / Source / Income Calculation / Annual Income
Total Gross Income
Transfer to Section 6 / $
Section 3 - ASSETS Part 1
Cash, Checking, Savings, Whole Life, (List exempt irrevocable assets: Term Life,Burial) etc.
MBR / Type / Source / Cash Value / Interest / Asset Income
#1 Subtotal / $ / #2Subtotal / $
Section 3 – ASSETS Part 2
(Certificates of Deposits, Real Estate, Stocks, Money Market, etc.)
MBR / Type / Source / Market Value / Int % / Asset Income / Divesture Cost
(cost to sell) / Cash Value
#3Subtotal / $ / #4Subtotal / $
Section 3 – ASSETS Part 3a
(Actual)
Total Cash Value of Assets #1 + # 4 Subtotals / $
Total Actual Income of Assets #2 + #3 Subtotals / $
Section 3 – ASSETS Part 3b
(Imputed)
If total cash value of assets(from Part 3a) is at or above $5000you must impute by passbook rate (2%)
X 2% / $
Transfer to section 6 the higher amount of actual income received from assets or imputed asset income
Section 4 - MEDICAL EXPENSES
MBR / Type / Source / Expense Calculation / Annually
$
$
$
$
$
$
$
$
$
Total Expenses / $
Section 5 – HOUSEHOLD ALLOWANCES:
Dependents: / Number of Dependents: / X $480 / = / $
Childcare Expense: / For children under 13 years: / = / $
Elderly Household / One Per Household: / $400 / = / $
Total Allowances
Transfer to Section 6 / $
Section 6 – CERTIFICATION CALCULATION:
Gross Income: / Income
(Transferred from section 2) / + / $
Asset Income
(Transferred from Section 3) / + / $
Total Gross Annual Income (GAI): / = / $
Deductions: / Total Medical Expenses / + / $
Total Handicap Care Expenses / + / $
Less 3% of Gross Annual Income (above) / - / $
Total Allowable Deductions: / - / $
Allowances: / (Allowances Total transferred from Section 5) / Total Allowances: / - / $
Adjusted Gross income AGI
(Transfer to Section 7) (GAI minus Deductions and Allowances) / = / $
Section 7 – RENT CALCULATION:
HUD ONLY: 214 Prorated Rent for Ineligible NON-Citizen YesNo
HUD ONLY: Minimum Rent Hardship Exception Requested (attach TC-50) YesNo Approved YesNo
(HUD or USDA-RD) / (PHA Section 8 Voucher Holders)
Gross Rent
(before utility allowance is deducted)
(AGI from Section 6 above divided by 12 x 30%) / $
Less Utility Allowance
(If applicable) / - / $ / Less Utility Allowance
(If applicable) / - / $
Tenant Rent:
(TP) (Net Rent) / + / $ / Tenant Rent:
(TP) (Net Rent) / + / $
Assistance Payment
(AP): / + / $ / Assistance Payment
(AP): / + / $
Contract/Basic/Market Rent (TP + AP): / = / $ / Contract/Basic/Market Rent (TP + AP): / = / $
Section 8 – INCOME LIMITS:
(Complete as applicable for your property)
HUD 30% Ex Low Limit
(Applies at M/I only) / $ / HTC Income Limit / $
Circle as appropriate: 30% 40% 50% 60% HOME
HUD Income Limit
(VL or EL) / $ / HTC Maximum Gross Rent
(From Rent Schedule) / $
USDA-RD Income Limit
(551/S8,VL, Low or Moderate) / $ / HTC 140% Limit
(Applies after M/I only) / $

Signature of PreparerDate

Resident Certification (02/2012)Page 1TC-59hr