ZERO INCOME/ MINIMAL INCOME WORKSHEET

This Checklist and worksheet is to be completed for all families whose TTP (Total Tenant Payment) equals the minimum rent.

FOOD EXPENSE YES NOAmount

Do you receive Food Stamps?
If yes, Monthly amount? / $
If no, What is your estimated monthlygrocery bill? / $
How is the grocery bill paid? ______
Does anyone contribute prepared (cooked) food to the family?
If yes, what is the monthly average value of the prepared food?
What is the total monthly cost for groceries and/or prepared food?
This amount is income / $

Personal and Household Supplies YES NOAmount

What is the average monthly value of paper products use by the family? (i.e.paper napkins, paper plates, toilet paper, paper towels, trash bags, disposable diapers (pampers) and other paper goods) This amount is income
How does the family pay for these products? ______
What is the average monthly value of grooming products use by the family? (i.e. soap, deodorant, shampoo, toothpaste, dental floss, cosmetics, hair color, etc.) This amount is income
How does the family pay for these products?
______
What is the average monthly value of the cleaning products used by the family? (i.e. dishwashing soap, laundry detergent, bleach and household cleaning products)?This amount is income
How does the family pay for these products?
______
Do you or someone in your household have your nails done? (acrylic, silk wrap, etc.)
How much contribution do you receive from family and/or friends to cover this cost monthly? This amount is income
What is the average monthly value of the cleaning products used by the family? (i.e. dishwashing soap, laundry detergent, bleach and household cleaning products)?This amount is income
Do you or someone in your household have their hair done?
How much contribution do you receive from family and/or friends to cover this cost monthly?This amount is income

Communications YES NOAmount

Do you have a telephone?
If yes, what is the monthly cost? This amount is income
Does any member of your household have a cell phone?
If yes, what is the monthly cost? This amount is income
(FOR FREE GOVERNMENT PHONES MUST PROVIDE PROOF.)

Transportation YES NOAmount

Do you have a car(s)? If no, skip to transportation part(2)
If yes, are payments due on the car? Yes ____ No____
If yes, what is the amount of the monthly car payments (s)?
This amount is income
What is the average weekly amount the family pays for gas?
This amount is income
What is the average monthly amount the family pays for Maintenance?
This amount is income
What is the average monthly amount the family pays for Insurance?
This amount is income

Transportation(part2) If the family doesn’t own a car YES NOAmount

What does the family use for transportation? (i.e. bus, rides, taxi, etc.) List here: ______
How much contribution do you receive from family and/or friends to cover this cost monthly?This amount is income

Entertainment YES NOAmount

Do you have cable or satellite TV? If yes, monthly cost?
Do you have a computer or tablet in your home?
If yes, is your computer or tablet connected to the internet?
What is the monthly cost for the internet service.
This amount is income
Do you purchase or have a subscription to magazines?
If yes, what is the monthly cost?This amount is income
Do you rent movies?
If yes, what is the monthly cost?This amount is income
Do you go on vacation?
If yes, what is the yearly cost?This amount is income
Do you attend sporting events?
If yes, what is the monthly cost?This amount is income
Are you a member of any club or gym?
If yes, what is the monthly cost?This amount is income
Do you purchase lottery tickets?
If yes, what is the weekly cost?This amount is income
Do you purchase liquor, beer or wine?
If yes, what is the weekly cost?This amount is income
Do you go to the night club?
If yes, what is the weekly cost?This amount is income

Smoking YES NOAmount

Does any member of the household smoke pipes, cigarettes or cigars?
If yes, what is the weekly cost? This amount is income

Clothing YES NOAmount

What is the monthly or yearly cost for clothing and shoes for your family?This amount is income / ______monthly
______yearly
Does the family have a washing machine in the home?
If no, what is the weekly amount spent for laundry?
This amount is income
What is the weekly amount spent for dry cleaning service?
This amount is income

Shelter Expense:

What is the average monthly cost for housing?
For tenants only (RRHA minimum rent) This amount is income
How much contribution do you receive from family and/or friends to cover this cost monthly?______
What is the average monthly amount forutilities/excess utilities?
How much contribution do you receive from family and/or friends to cover this cost monthly?This amount is income

Miscellaneous expense YES NOAmount

Do you rent any furniture,appliance or electronics?
How much contribution do you receive from family and/or friends to cover this cost monthly?This amount is income
Listed below are a series of expenses? Indicate the monthly amount the family spends on any applicable expense.
Unreimbursed medical expense? ______
Unreimbursed Educational Expenses $ ______
Church contributions $______
Unreimbursed Child care expenses $ ______
How much contribution do you receive from family and/or friends to cover this cost monthly?

Total Contribution from all sources (Cash or in kind): ______(This amount is considered income)

Please complete the following:

  • Do you have a checking or savings account? ______If yes, what is your current balance the account? Amount $ ______Location ______
  • Are you enrolled full time or part time in school? ______If yes, where?______How is tuition/books being paid for? ______.
  • Are you currently seeking employment ______? If NO, explain why ______

______

  • If yes how long have you been looking for work? ______
  • Did you file a tax return last year? ______
  • Have you applied for any of the following:Circle all that apply:TANF Unemployment General relief Child Support Workman’s Comp Social Security/ SSI
  • If you answered yes to the above, please provide the status:______

______

Under penalty of perjury, I certify that the information in this certification is true and accurate to the best of my knowledge. I further understand that false representation constitutes an act of fraud. False, misleading or incomplete information may result in the termination of housing assistance and termination of tenancy.

______

Signature of Applicant / TenantDate

______

Signature of RRHA StaffDate