TENANT INCOME CERTIFICATION Effective Date:
Initial Certification Recertification Other: Move-in Date:
PART I - DEVELOPMENT DATA
Property Name: BIN #: PISD:
Address: County: Unit No: # BR:
DEMOGRAPHIC INFO
PART II. HOUSEHOLD COMPOSITION (Required for LIHTC/HMMF Projects)
Date of SSN
Hsld First Name & Middle Relationship F/T
Last Name Birth (last 4 Race Ethnicity Disabled
Mbr # Initial to Head Student
(mm/dd/yyyy) digits)
1 HEAD
2
3
4
5
6
7
8
PART III. GROSS ANNUAL INCOME (USE ANNUAL AMOUNTS)
Hsld
(A) Employment or Wages (B) Soc. Security/Pensions (C) Public Assistance (D) Other Income
Mbr #
TOTALS $0.00 $0.00 $0.00 $0.00
Add totals from (A) through (D), above TOTAL INCOME (E): $0.00
PART IV. INCOME FROM ASSETS
Hshld
(F) Type of Asset (G) C/I (H) Cash Value of Asset (I) Annual Income from Asset
Mbr #
Total Cash Value TOTALS: $0.00 $0.00
If (H) is over $5000 $0.00 X Passbook Rate: 2% = (J) Imputed Income $0.00
Enter the greater of the total of column I, or J: imputed income TOTAL INCOME FROM ASSETS (K) $0.00
(L) Total Annual Household Income from all Sources Add (E) and (K) $0
HOUSEHOLD CERTIFICATION & SIGNATURES
The information on this form will be used to determine maximum income eligibility. I/we have provided for each person(s) set forth in Part II acceptable
verification of current anticipated annual 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
Signature Date Signature HHFDC TIC
Date
1 December 2010
PART V. DETERMINATION OF INCOME ELIGIBILITY
TOTAL ANNUAL HOUSEHOLD LIHTC RECERT ONLY:
Household Meets
INCOME FROM ALL SOURCES: $0 Income Restriction at:
Current Income Limit x 140%:
From item (L) on page 1 $0.00
60% 50% Household Income exceeds
40% 30% 140% at recertification:
Yes No
Current Maximum Income Limit per Family Size:
Household Income at Move-in Household Size at Move-in:
PART VI. RENT
Tenant Paid Rent Rent Assistance Type(s)
Utility Allowance Other non-optional
GROSS RENT FOR UNIT: Unit Meets Rent Restriction at:
$0.00
(Tenant paid rent plus Utility Allowance 60% 50% 40%
& other non-optional charges) 30%
LITHC Maximum Rent Limit for this unit:
PART VII. STUDENT STATUS
ARE ALL OCCUPANTS FULL TIME STUDENTS? If yes, Enter student explanation* * Student Explanation:
yes no (also attach documentation) 1 TANF assistance
Enter 1-5: 2 Job Training Program
3 Single parent/dependent child
4 Married/joint return
5 Formerly in foster care
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 b. HOME c. Tax Exempt d. e.
(Name of Program) (Name of Program)
See Part V above. Income Status Income Status Income Status Income Status
<=50% AMGI <=50% AMGI
<=60% AMGI <=60% AMGI
<=80% AMGI <=80% AMGI
OI** OI** OI**
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 proofs 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 a unit in this Project.
SIGNATURE OF OWNER/REPRESENTATIVE DATE
HHFDC TIC
2 December 2010
Rental Assistance Program
TIC Worksheet
GENERAL RAP REQUIREMENTS
To qualify for residence in an Eligible Project, an applicant must:
Meet the qualified owner’s reasonable tenant selection requirement designed to select responsible tenants
Meet the program income limits
To be eligible for RAP, an applicant must:
Not have had rental assistance payments previously terminated because of fraud.
Meet the program income limits
Total Annual Household Income from All Sources $0
Rental Assistance Annual Income Limit for Family Size (80% of Median Income)
Household eligible or ineligible for RAP:
RENT & SUBSIDY BREAKDOWN: RAP, S8 VOUCHER, AND/OR RENTAL SUPPLEMENT
I. Rental Assistance Program
1. Contract Rent Utility Allowance (UA) Paid by Tenant
2. Less Tenant Contribution Total Household Income/12 x 30% less UA if tenant pays
3. Remaining Rent Due Line 1 minus Line 2.
4. Less Rental Assistance Payment Maximum Payment allowed is:
5. Shortfall Due from Tenant Line 3 minus Line 4.
6. Total Tenant Contribution Line 2 plus Line 5. Cannot exceed limit above.
II. Rental Assistance Program and Rent Supplement Program *
1. Contract Rent Utility Allowance (UA) Paid by Tenant
2. Less Tenant Contribution Total Household Income/12 x 30% less UA if tenant pays
3. Remaining Rent Due Line 1 minus Line 2.
4. Less Rental Assistance Payment Maximum Payment allowed is:
5. Remaining Rent Due Line 3 minus Line 4.
6. Apply Rent Supplement Payment
a. Total Tenant Obligation Line 2 plus Line 5.
b. Less Rent Supplement Payment Provided by Rent Supplement Office
c. Shortfall Due to Tenant **
7. Total Tenant Contribution Cannot exceed limit above.
III. Rental Assistance Program and Section 8 Voucher Program *
1. Contract Rent
2. Less Rental Assistance Payment Maximum Payment allowed is:
3. Net Rent to Section 8 Payment Standard less utilities
4. Less Section 8 Subsidy Payment As Determined by State/City/County Section 8
5. Total Tenant Contribution As Determined by State/City/County Section 8
*Changes need to be reported to the appropriate Rent Supplement or Section 8 office.
** If there is a negative shortfall due to the tenant, the Rental Assistance Portion should be adjusted to prevent
overpayments.
HHFDC RAP TIC Worksheet
December 2010
SELF-CERTIFICATION OF ANNUAL INCOME (LIHTC Only)
To be completed for the second annual recertification and Effective Date:
all subsequent recertifications in 100% tax credit projects.
Move-in Date:
PART I - DEVELOPMENT DATA
Property Name: BIN #: PISD:
Address: County: Unit No: # BR:
SECTION TO BE COMPLETED BY RESIDENT
HOUSEHOLD: Enter all household member name(s) and date(s) of birth below. Also note whether or not any household member is or
will be a fulltime student in next 12 months. Continue on separate sheet of paper if necessary.
PART II. HOUSEHOLD COMPOSITION DEMOGRAPHIC INFO**
SSN
Hsld First Name & Middle Relationship to Date of Birth F/T
Last Name (last 4 Race Ethnicity Disabled
Mbr # Initial Head (mm/dd/yyyy) Student
digits)
1 HEAD
2
3
4
5
6
7
8
* If all occupants are full time students, attach completed Housing Student Status Verification form.
** For Demographic Codes, reference Tenant Income Certification (TIC) Instructions.
PART III. GROSS ANNUAL INCOME (USE ANNUAL AMOUNTS)
INCOME: Enter household income including income from assets of each adult household member. If some members have no income put
“Zero.” Every adult Household member must sign below to certify their gross annual income anticipated for the next 12 months. See
NOTES on second page of this form. Continue on separate sheet of paper if necessary.
Hsld Gross Annual Income & Income
Signature of Adult(s)
Mbr # from Assets
1
2
3
4
5
6
7
8
Total Annual Household Income from all Sources $0
HHFDC LIHTC Self-Certification of Annual Income
4 November 2010
Property Name: 0 Unit: 0
Household Name: 0 BIN: 0
I agree to notify management IMMEDIATELY if:
w Anyone in my household becomes a fulltime student, and/or
w My household composition changes in any way.
I certify under penalties of perjury that the above information is true and complete to the best of my knowledge. I understand that false or
incomplete information is a violation of the terms of my lease and is grounds for eviction. I agree to furnish any additional income or other
documentation required by the property owner/management to document my/our household income:
Head of Household Signature Print Name Date
Other Household Adult Signature Print Name Date
Other Household Adult Signature Print Name Date
Other Household Adult Signature Print Name Date
NOTES
Types of Income: Possible types of income include but are not limited to: wages, salary, tips, bonuses, commissions, military
pay, public assistance, Social Security/SSI, retirement benefits, VA benefits, child support, regular gifts, unemployment, and
some types of financial aid, and income earned on assets (checking, savings, IRA, etc.). Include what you receive now and
what you anticipate receiving in the next 12 months. All income listed must be GROSS income (income before taxes and
deductions).
Income from Assets: Income from assets must also be included in Total Gross Annual Income. Possible types of assets
include, but are not limited to: checking accounts, savings accounts, cash on hand, money market accounts, certificates of
deposit, stocks, bonds, 401(k) and real estate. Include the annual interest from these accounts in your total income.
SECTION TO BE COMPLETED BY MANAGEMENT
MOVE-IN: CURRENT RECERTIFICATION:
Original Move-In Date: 01/00/00 Effective Date of Recertification: 01/00/00
Set-Aside %: Total Gross Annual Income: $0.00
Household Portion of Rent:
Total Annual Household
Income at Move-In: Utility Allowance:
Subsidy Portion:
Subsidy Type:
Signature of Management Representative Print Name Date
HHFDC LIHTC Self-Certification of Annual Income
5 November 2010