income verification worksheet

							                                   IDA Program Name
                               Income Verification Worksheet


                                   Household Information

Applicant’s Name: ______________________________________________________________

How many adults (18yrs and older) currently live in participant’s household: ____________
How many children (under 18yrs) currently live in participant’s household: _____________
How many adults and/or children do not live with the participant
but should be considered part of the participant’s household unit: _______________
Total household size: ________________
Program income limit for household of this size: $________________

                                           Income

                                               Annual              Documentation:
             Category                          Amount        Tax Return  Other Source(s)
   Formal employment (wages)               $____________                   _______________
   Self-employment                         $____________                   _______________
   Government assistance                   $____________                   _______________
   Pensions or retirement income           $____________                   _______________
   Child support /alimony payments         $____________                   _______________
   Friends or family                       $____________                   _______________
   Investment income                       $____________                   _______________
   Other (specify: _____________)          $____________                   _______________

   Total                                   $____________

                                     Participant Status

 Applicant qualifies for participation based on his/her documented household income
 Applicant does not qualify for participation based on his/her documented household income

IDA Program Name Staff: __________________________________              Date: _____________