ASSETS
DATE: ______________ ANALYST: ___________________________ REFERENCE NO.: _____________
Household Member Name: ____________________________________________ Source Document: _________________________
Paid Hourly: $ __________________base pay per hour x 2080 working hours per year = $__________________
Annual Income
YTD: ________________ $______________ ÷ _____________ = $_____________ x 2080 hours = $__________________
Dates covered Amount # of Days* Daily Income Annual Income
YTD: ______________ $________________ ÷ _______________ x 24 (bi-monthly) = $__________________
Dates covered Amount # of Pay Periods or 26 (every 2 weeks) Annual Income
Fixed Income: Pension / SSI / SSA (use GROSS from Letter or Paystub): $______________ x 12 = $ ________________
Annual Income
===================================================================================================================
Household Member Name: ____________________________________________ Source Document: _________________________
Paid Hourly: $ __________________base pay per hour x 2080 working hours per year = $__________________
Annual Income
YTD: ________________ $______________ ÷ _____________ = $_____________ x 2080 hours = $__________________
Dates covered Amount # of Days* Daily Income Annual Income
YTD: ______________ $________________ ÷ _______________ x 24 (bi-monthly) = $__________________
Dates covered Amount # of Pay Periods or 26 (every 2 weeks) Annual Income
Fixed Income: Pension / SSI / SSA (use GROSS from Letter or Paystub): $______________ x 12 = $ ________________
Annual Income
===================================================================================================================
Self Employment Income:
Household Member Name: _____________________________
Last Tax Return Schedule C Net Income: $ _______________
+ Net Income from Profit and Loss covering period from end of last tax return through present + $ _______________
+ ALL Depreciation, One-Time Costs, Startup Costs, Expansion Costs, Amortization of Capital Indebtedness + $ _______________
TOTAL = $ ________________
TOTAL $ _________________ ÷ number of months covered = $ _________________ x 12 = $ ______________________
. Monthly Income Annual Income
===================================================================================================================
*To annualize YTD:
STEP 1: Establish number of days the information covers
Computation: YR MO DAY end date of information
- YR MO DAY start date of information
Convert months to days (8 x 30 = 240), add any remainder days
STEP 2: Divide YTD figure by calculated number of days to get daily
amount earned
STEP 3: Multiply daily figure by 2080 hours if indication is that wages are earned 40 hours per week; adjust for other than 40 hour work week. This
provides the annual figure.
-----------------------
Use a 30 day month and “borrow” months or days to calculate
Example: 07 05 01 “borrow 1 month (days = 31)
- 06 08 31 then “borrow” 1 year (months =16)
8 0
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