Client ID: ________ Date: ________
Non-Borrower Income Form
This form is to be used to demonstrate “Non-Borrower Household Income” as defined in Bulletin 2011-14
(Revised). This form replaces the Cohabitant Income Form.
Instructions: Restoring Stability will include non-borrower household income in total household monthly gross
income if it is voluntarily provided by the borrower and if the income reasonably can continue to be relied upon
to support the mortgage payment. Non-borrower household income included in the total household monthly
gross income must be documented using the same standards for verifying a borrower’s income. The
homeowner must provide documentation of the occupancy of the non-borrower.
Non-borrower household income may be used to demonstrate sustainability for Rescue Payment Assistance or
demonstrate a 10 percent loss of income to qualify for the underemployment hardship.
Demonstrating sustainability for Demonstrating loss of income to qualify for underemployment
Rescue Payment Assistance hardship
• Non-borrower Income Form • Non-borrower Income Form
• Documentation of non-borrower • Proof of non-borrower occupancy in the property during the
occupancy of the property for at three-month base period during which base income is
least two months prior to the established
date of application • 60 days of non-borrower bank statements
• 60 days of non-borrower bank • Last 60 days of pay stubs for all non-borrower employment and
statements income sources
• Last 60 days of pay stubs for all • Proof of non-borrower involuntary loss of income or proof—such
non-borrower employment and as verification of residency in another property, death certificate,
income sources obituary, or other documentation—that the non-borrower no
longer resides in the home
• Proof that the non-borrower contributed toward household
expenses during the three-month base period
By completing this form, you elect to include non-borrower household income in the calculation of total
Relationship to homeowner:
Date of initial occupancy: Length of occupancy:
Client ID: ________ Date: ________
Choose one: I am completing this form to:
☐ demonstrate sustainability for Rescue Payment Assistance.
_____ /_____ I/we certify my/our permanent or temporary residence at the above address. I/we will
contribute wages or rent toward the total household income of the above homeowner for a period of at
least six months after Restoring Stability Assistance begins. I/We will provide documentation of occupancy,
last 60 days of bank statements, and last 60 days of income.
Source of non-borrower income: Other (Please Specify
Frequency of non-borrower income: Other (Please Specify)
☐ demonstrate loss of income to qualify for underemployment hardship.
_____ /_____ I/we certify my/our permanent or temporary residence at the above address. I/we
contributed wages or rent toward the total household income of the above homeowner for a period of at
least six months before experiencing a loss of income. I/We will provide documentation of occupancy, last
60 days of bank statements, last 60 days of income, and proof of loss of income.
Does the non-borrower(s) currently occupy the property? Yes ☐ No ☐
Source of non-borrower income, prior to loss: Other (Please Specify
Frequency of non-borrower income prior to loss: Other (Please Specify)
Source of current non-borrower income: Other (Please Specify
Frequency of current non-borrower income: Other (Please Specify)
Reason for loss of income: Other (Please Specify)
Your signatures indicate that the homeowner(s) and non-borrower(s) agree that the combined income is/was a
reflection of the total household income. If this income changes, it is the responsibility of the homeowner to
notify their counseling agency. In addition, if it is determined that fraudulent information was provided, or
failure to notify the State of events stated above, your enrollment will be automatically terminated and you may
be notified that you must pay back the assistance that you received.
Homeowner Signature Date
Co-Homeowner Signature Date
Non-Borrower(s) Signature Date