HOUSEHOLD NAME: ______DATE: ______HMIS/ DV ID #: ______

NC ESG Income and Asset Calculation Worksheet

This worksheet is to be utilized by Rapid Re-Housing and Prevention providers. For Rapid Re-Housing it must be done after aid has been rendered for one year. For Prevention, this form is to be completed at program admission as a part of eligibility screening, and as part of the recertification process every three months. Consumer’s income must be at or below 30% of AMI.

In all cases of homelessness, HUD has a preferred order for documentation. The best documentation to use is written, 3rd party documentation, followed by oral 3rd party, followed by Intake Staff Observations (only applicable where indicated), and Self-Certification (only applicable where indicated).

Assets

Column A / Column B / Column C / Column D / Column E / Column F
Household Member # / Asset Type / Cash Value of Asset / Interest Rate (%) / Actual Annual Income / Description/Notes

Income

Column G / Column H / Column I / Column J
Household Member # / Source of Income / Calculation: Gross Amount X Pay Period / Annual Income
  1. Total Income $______
  1. Total Income from Assets $ ______
  1. Total Annual Income (Line 1 plus Line 2) $ ______

4.  30% of AMI for your area $ ______

Household is income ineligible if line 3 is greater than line 4 (assuming calculations are correct)

Verified by: Date

Documentation Attached (please list):

NC ESG Calculating Gross Income

Weekly

$______(wages) X 40 (hours) X 52 (weeks) = ____

Bi-weekly

$______(wages) X 80 (hours) X 26 (weeks) = ____

Semi-Monthly

$______(wages) X 80 (hours) X 24 (weeks) = ____

(paid on 15th and 30th of each month)

Annually

$______(monthly) X 12 (weeks) = ____

Note:

If pay stub indicates annual salary, please use documented amount.

If Verification of Employment indicates hours, please use documented amount to calculate.

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2.4 NC ESG Income and Asset Calculation Worksheet REV 1.25.17