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77060962v1 <br /> <br /> <br /> B-1-1 <br /> <br />EXHIBIT B–1 <br />FORM OF INITIAL INCOME CERTIFICATION <br /> <br />TENANT INCOME CERTIFICATION Effective Date: _____________________ <br />Move-in Date: _____________________ <br /> <br /> <br /> Initial Certification Recertification Other* _________ <br />PART I. DEVELOPMENT DATA <br />Property Name: ________________________________ <br />Address: _____________________________________ <br />County: _______________ <br />Unit Number: ___________ <br />BIN #: __________ <br /># Bedrooms: _____ <br />PART II. HOUSEHOLD COMPOSITION <br />HH Mbr # <br /> <br />Last Name <br />First Name & <br />Middle Initial <br />Relationship <br />to Head of <br />Household <br />Date of Birth <br />(MM/DD/YY <br />) <br />F/T <br />Student <br />(Y or N) <br />Social <br />Security or <br />Alien Reg. <br />No. <br />1 HEAD <br />2 <br />3 <br />4 <br />5 <br />6 <br />7 <br />PART III. GROSS ANNUAL INCOME (USE ANNUAL AMOUNTS) <br />HH Mbr # (A) (B) (C) (D) <br />Employment or Wages Soc. Security / Pensions Public Assistance Other Income <br /> <br /> <br /> <br /> <br /> <br />TOTALS <br /> Add totals from (A) through (D) above TOTAL INCOME (E): <br /> <br />