PART II - Iowa Finance
PART II. HOUSEHOLD COMPOSITION -ContinuedHHMbr #Last NameFirst Name Middle InitialRelationship to Headof HouseholdRaceEthnicityDisabledDate of Birth F/T StudentLast 4 digits of SSN8 FORMTEXT ????? FORMTEXT ????? FORMTEXT ??Head FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMTEXT ????9 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMTEXT ????10 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMTEXT ????11 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMTEXT ????12 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMTEXT ????13 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMTEXT ????PART III. GROSS ANNUAL INCOME (USE ANNUAL AMOUNTS) -ContinuedHHMbr #(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 ?????TOTALS $ FORMTEXT ????? $ FORMTEXT ????? $ FORMTEXT ????? $ FORMTEXT ?????Add totals from all pages (A) through (D) 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 Rate If over $5000$ FORMTEXT ?????X 0 .06%=(J) Imputed Income$ FORMTEXT ?????Enter the greater of the total of column I, or J-all pages: 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)Signature(Date)Signature(Date)Signature(Date)Signature(Date)Signature(Date)Signature(Date) ................
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