|
INCOME CHECK LIST
Check YES or
NO on ALL lines below. If YES, show amount at right.
Name:
_____________________________________________________
Date: ______________________________
YES
NO
INCOME
AMOUNT
____ ____ I receive monthly income from employment.
_________
____ ____ I receive
support from parents or relatives. _________
____ ____ I receive payments from workmen’s
compensation. __________
____ ____ I receive
Veteran’s Administration benefits. __________
____ ____ I receive G.
I. Bill benefits.
__________
____ ____ I receive
disability or death benefits.
__________
____ ____ I receive
Social Security. (Proof
required.) ___________
____ ____ I receive Supplemental Security Income
(S.I.I.) _________
(Proof required.)
____ ____ I receive
Public Assistance (AFDC). (Proof
required.) ___________
____ ____ I receive
DEFRA. (Proof
required.)
___________
____ ____ I receive
educational grants or scholarships. (Proof
required.) ___________
____ ____ I receive
unemployment benefits. (Proof
required.) ___________
____ ____ I receive child support or
alimony. _________
____ ____ I receive
periodic payments from insurance policies.
_________
____ ____ I receive periodic payments from
retirement funds or
_________
pensions.
____ ____ I receive income from rental, real, or personal
property ________
List ALL person(s) including yourself who will be residing in the unit more
than 50% of the time:
__________________________________
______________________________
__________________________________
______________________________
__________________________________
______________________________
__________________________________
______________________________
Signature
Date |
