TENANT INCOME CERTIFICATION Effective Date:
Move-In Date:
(MM/DD/YYYY)
PART 1. DEVELOPMENT DATA
Arroyo Villas
Property Name: County: Bernalillo BIN#
Address: 4701 Irving Blvd NE Unit# #Bedrooms
PART II. HOUSEHOLD COMPOSITION
HH First Name & Middle Relationship to Head of Date of Birth F/T Student Social Security or
Mbr# Last Name Initial Household (MM/DD/YYYY) (Y or N) Alien Reg. No.
1
2
3
4
5
6
7
PART III. GROSS ANNUAL INCOME (USE ANNUAL AMOUNTS)
HH (A) (B) (C ) (D)
Mrb# Employ. Or Wages Soc. Sec / Pension Public Assistance Other Income
Totals: $ $ $ $
Add totals from (A) through (D), above TOTAL INCOME: $
PART IV. INCOME FROM ASSETS
Hshld (F) (G) (H) (I)
Mbr# Type of Asset C/I Cash Value of Asset Annual Income from Asset
TOTALS: $ $
Enter Column (H) Total Passbook Rate
if over $5000 $ _______ x 2.00% = (J) Imputed Income $
Enter the greater of the total of column I, or J: Imputed income TOTAL INCOME FROM ASSETS (K)
(L) Total Annual Household Income from all Sources [Add (E) + (K)] $
HOUSEHOLD CERTIFICATION & SIGNATURES
The information on this form will be used to determine maximum income iligibility. I/we have provided for each person(s) set forth in Part II
acceptable verification of current anticipated income. I/we agree to notify the landlord immediately upon any member of the household moving
out of the unit or any new member moving in. I/we agree to notify the landlord immediately upon any member becoming a full time student.
Under penalties of perjury, I/we certify that the information presented in this Certification is true and accurate to the best of my/our knowledge
and belief. The undersigned further understands that providing false representations herein constitutes an act of fraud. False, misleading or
incomplete information may result in the termination of the lease agreement.
Signature (Date) Signature (Date)
Effective Date of Income Certification Household Size at Certification
(YYYY-MM-DD)
PART V. DETERMINATION OF INCOME ELIGIBILITY
TOTAL ANNUAL HOUSEHOLD RECERTIFICATION ONLY:
INCOME FROM ALL SOURCES: $
From item (L) on page 1
Current Income Limit Current Income Limit x 140%
Per Family Size: $ $
Household Meets Income Restricition at: Household Income exceeds
p60% p50% p40% p30% p ____% 140% at recertification: p Yes p No
Household Size at Move-In:
PART VI. RENT
Tenant Paid Rent (TP) $ Other non-optional charges: $
Utility Allowance (UA) $ Rent Assistance*: $
(*For LIHTC/HOME units only, include as GROSS RENT
GROSS RENT FOR UNIT:
(TP + UA + Other non-optional charges) $ Unit Meets Rent Restriction at:
p60% p50% p40% p30% p_____%
Maximum Rent Limit for this unit: $_______________
PART VII. STUDENT STATUS
ARE ALL OCCUPANTS FULL TIME STUDENTS? *Student Exemptions:
1. TANF assistance
p Yes p No If yes, enter student exemption* 2. Job Training Program
3. Single parent/dependent child
Enter 4. Married/joint return
Exemption #:______ 5. Previous Foster Care Assistance
6. Extended Use Period (student
status rules do not apply)
PART VIII. PROGRAM TYPE
Mark the program(s) listed below (a. through e.) for which this household's unit will be counted toward the property's
occupancy requirements. Under each program marked, indicate the household's income status as established by this
certification/recertification.
a. Tax Credit p b. HOME p c. Tax Exempt p d. AHDP p e. __________ p
(Name of Program)
See Part V above Income Status Income Status Income Status Income Status
p 50% AMGI p 50% AMGI p 50% AMGI p
p 60% AMGI p 60% AMGI p 80% AMGI p
p 80% AMGI p 80% AMGI p OI** p
p OI** p OI** p OI**
**Upon recertification, household was determined over-income (OI) according to eligibility requirements of the program(s) marked above.
SIGNATURE OF OWNER/REPRESENTATIVE
Based on the representations herein and upon the proof and documentation required to be submitted, the individual(s) named in Part II of this Tenant
Income Certification is/are eligible under the provisions of Section 42 of the Internal Revenue Code, as amended, and the Land Use Restriction Agreement
(if applicable) to live in an income/rent-restricted unit in this Project.
Printed Name of Owner/Representative Signature of Owner/Representative Date