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73505919v2 <br /> <br /> <br /> B-1-2 <br /> <br />PART IV. INCOME FROM ASSETS <br />HH Mbr <br /># <br />(F) (G) (H) (I) <br />Type of Asset C/I Cash Value of Asset Annual Income from <br />Asset <br /> <br /> <br /> <br /> <br /> <br />TOTALS: $ <br />Total Cash Value Passbook Rate <br />If (H) is over $5,000 $________________ x .06 % = (J) Imputed Inc. <br />Enter the greater of the total column I, or J: imputed income TOTAL INCOME FROM ASSETS (K) <br /> <br /> <br /> <br />(L) Total Annual Household Income from all Sources Add (E) and (K) <br />HOUSEHOLD CERTIFICATION & SIGNATURES <br />The information on this form will be used to determine maximum income eligibility. I/we have provided for each <br />person(s) set forth in Part II acceptable verification of current anticipated annual income. I/we agree to notify the <br />landlord immediately upon any member of the household moving out of the unit or any new member moving in. <br />I/we agree to notify the landlord immediately upon any member becoming a full time student. <br />Under penalties of perjury, I/We certify that the information presented in this Certification is true and accurate to <br />the best of my/our knowledge and belief. The undersigned further understands that providing false representations <br />herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination of <br />the lease agreement. <br /> <br />_____________________ <br />Signature <br />____________________ <br />(Date) <br />_____________________ <br />Signature <br />____________________ <br />(Date) <br />_____________________ <br />Signature <br />____________________ <br />(Date) <br />_____________________ <br />Signature <br />____________________ <br />(Date) <br />