RES 539 Monthly Income Verification
Project Title: Parcel No.: Displaced Person(s): Displacee No.: 1. Displacee – Head of Household2. Displacee – Spouse/PartnerEmployer: Employer: Employer’s Address: Telephone: Employer’s Address: Telephone: City: State: Zip Code: City: State: Zip Code: Occupation: Occupation: 3. Income – Documentation RequiredDisplacee NameRelationshipIncome per MonthGross Wagers or Salary, before TaxesRetirementBenefits PaymentsSocial SecurityPensions, OtherDisabilityUnemploymentPublic AssistanceNOTE: Exclude income of minors (children under 18 years of age or full-time students that live at home) Income Total4. Other Income – Documentation RequiredNameNameNet Income from BusinessGross Overtime Pay, Commissions, Tips and BonusesAlimony and Child SupportWorker’s CompensationMilitary Pay (Include Regular, Reserve, Special Pay and/or Allowances)Veteran’s Payments or BenefitsInterest and Dividend IncomeMiscellaneous other Sources Other Income Total5. Total Monthly Gross Income: $Remarks____________________________________________________________________________________________________________Applicant Signature:Date:I, (We) certify under the penalties of perjury, that my/our average monthly gross income, including salaries, wages, tips, commission, rents, royalties, dividends, interest, profits, pensions and annuities, irrespective of expanses and voluntary or involuntary deductions, is correctly stated above. I (We) understand that this information may be used in connection with a Federal-Aid highway project. I (We) understand that inquires will be made by WSDOT to verify the statements herein and that I will provide additional supporting documentation. ................
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