MIDWEST REGION - Iowa Finance Authority
FORMCHECKBOX Initial Certification FORMCHECKBOX Recertification FORMCHECKBOX Other FORMTEXT ?????Effective Date: FORMTEXT ?????Move in Date: FORMTEXT ?????PART I. DEVELOPMENT DATAProperty Name: FORMTEXT ?????Project # FORMTEXT ?????BIN: IA- FORMTEXT ?????Address: FORMTEXT ?????Unit # FORMTEXT ?????County: FORMTEXT ?????# Bedrooms FORMTEXT ?????PART II. HOUSEHOLD COMPOSITIONHHMbr #Last NameFirst Name Middle InitialRelationship to Headof HouseholdRaceEthnicityDisabledDate of Birth F/T StudentLast 4 digits of SSN1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ??Head FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMTEXT ????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMTEXT ????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMTEXT ????4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMTEXT ????5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMTEXT ????6 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMTEXT ????7 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMTEXT ????PART III. GROSS ANNUAL INCOME (USE ANNUAL AMOUNTS)HHMbr #(A)Employment or Wages(B)Soc. Security/Pensions(C)Public Assistance(D)Other Income FORMTEXT ??$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ??$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ??$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ??$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ??$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????TOTALS$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Add totals from (A) through (D), above TOTAL INCOME (E):$ FORMTEXT ?????PART IV. INCOME FROM ASSETSHH Mbr #(F)Type of Asset (G)C/I(H)Cash Value of Asset (I)Annual Income from Asset FORMTEXT ????? FORMTEXT ????? FORMTEXT ???$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???$ FORMTEXT ?????$ FORMTEXT ?????TOTALS:$ FORMTEXT ?????$ FORMTEXT ?????Enter Column (H) Total Passbook RateIf over $5000$ FORMTEXT ?????X0.06%=(J) Imputed Income$ FORMTEXT ?????Enter the greater of the total of column I, or J: imputed income TOTAL INCOME FROM ASSETS (K)$ FORMTEXT ????? (L) Total Annual Household Income from all Sources [Add (E) + (K)]$ FORMTEXT ?????HOUSEHOLD CERTIFICATION & SIGNATURESThe 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 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(Date)PART V. DETERMINATION OF INCOME ELIGIBILITYLIHTC RECERTIFICATION ONLY:TOTAL ANNUAL HOUSEHOLD INCOME FROM ALL SOURCES:From item (L) on page 1$ FORMTEXT ?????Household Meets Income Restriction at:Designated Income Limit x 140% (or 170% DRS)$ FORMTEXT ?????(Units at 50% or below in Average Income Test properties use 60% for Designated Income Limit)Household Income exceeds 140% (or 170% DRS)at recertification? FORMCHECKBOX Yes FORMCHECKBOX NoCurrent Income Limit per Family Size:$ FORMTEXT ????? FORMCHECKBOX 80% FORMCHECKBOX 70% FORMCHECKBOX 60% FORMCHECKBOX 50% FORMCHECKBOX 40% FORMCHECKBOX Deep Rent Skew (DRS) FORMCHECKBOX 30% FORMCHECKBOX 20% FORMCHECKBOX Other FORMTEXT ?????Household Income at Move-in:$ FORMTEXT ?????Household Size at Move-in: FORMTEXT ?????PART VI. RENTTenant Paid Rent$ FORMTEXT ?????Rental Assistance (if any): $ FORMTEXT ?????Utility Allowance$ FORMTEXT ?????Rental Assistance Type (if any) FORMTEXT ?????Other non-optional charges:$ FORMTEXT ?????Unit Meets Rent Restriction at: FORMCHECKBOX 80% FORMCHECKBOX 70% FORMCHECKBOX 60% FORMCHECKBOX 50% FORMCHECKBOX 40% FORMCHECKBOX 30% FORMCHECKBOX 20% FORMCHECKBOX Other FORMTEXT ?????%GROSS RENT FOR UNIT*:$ FORMTEXT ?????(Tenant paid rent plus Utility Allowance & other non-optional charges)Maximum Rent Limit for this unit:$ FORMTEXT ?????PART VII. STUDENT STATUSLIHTC -if applicable: Are all Occupants full time students? FORMCHECKBOX Yes FORMCHECKBOX NoHOME or National Housing Trust Fund -if applicable: Are any household members students at an institute of higher learning? FORMCHECKBOX Yes FORMCHECKBOX NoPART VIII. PROGRAM TYPEMark 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. FORMCHECKBOX LIHTC b. FORMCHECKBOX LIHTC Agency Covenantsb. FORMCHECKBOX HOMEc. FORMCHECKBOX Tax Exempt Housing Bondd. FORMCHECKBOX National Housing Trust Fundf. Other FORMTEXT ?????See Part V above. Income Status FORMCHECKBOX 30% AMGI FORMCHECKBOX 40% AMGI FORMCHECKBOX 50% AMGI FORMCHECKBOX OI**Income Status FORMCHECKBOX 50% AMGI FORMCHECKBOX 60% AMGI FORMCHECKBOX 80% AMGI FORMCHECKBOX OI**Income Status FORMCHECKBOX 50% AMGI FORMCHECKBOX 60% AMGI FORMCHECKBOX 80% AMGI FORMCHECKBOX OI**Income Status FORMCHECKBOX 30% AMGI/ Poverty Line FORMCHECKBOX 50% AMGI FORMCHECKBOX OI**Income Status FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX OI****Upon recertification, household was determined over-income (OI**) according to eligibility requirements of the program(s) marked above.SIGNATURE OF OWNER/REPRESENTATIVEBased 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/REPRESENTATIVEDate ................
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