_______________________________________ 

_______________________________________ 

_______________________________________ 

____________________________________ 

 

[Management Agent Letterhead] 

EMPLOYMENT VERIFICATION 

To: _______________________________________ Date: 

_____________________________________________ has applied for residency/ is a 

resident at _______________________________________. As part of our processing, it is 

necessary that we obtain verification of his/her employment and anticipated GROSS annual 

income. The attached release and consent form authorizes the release of information 

regarding the applicant's employment and income. 

Please complete the section below and return it in the enclosed self-addressed 

stamped envelope. (Please mail rather than have the above individual hand deliver.) Thank 

you in advance for your prompt attention. 

Sincerely, 

(Apartment Manager) 

THE FOLLOWING TO BE COMPLETED BY EMPLOYER: 

Anticipated Gross Income for the Next Twelve Months 

Hourly $____________ 

No. of hours per week_____ 

Weekly $____________ 

Bi-weekly $____________ Monthly $____________ 

Overtime: Average per $____________ 

Day 

$____

Week

________ $________________ 

Month 

Tips, Commissions, Bonuses: 

Average per $____

$______________ 

Year 

________ 

Day 

$____

Week 

________ $_________________ 

Month 

- or ­

F-1
 
______________________________________________ _______________________________ 

Total anticipated gross annual income for the next twelve months (including tips, bonuses or
 

overtime if applicable)
 

$_________________________.
 

Employer's Signature	 Date 

______________________________________________(____)__________________________

 Title Telephone 

WARNING:	 Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements 

or misrepresentations to any Department or Agency of the United States as to any matter within its 

jurisdiction. 

F-2
 
______________________________________________________________________________ 

_________________________ 

[Management Agent Letterhead] 

ASSET VERIFICATION 

Name and 

Address of Bank: __________________________________________________________________ 

RE:	 __________________________________ SSN: ______________________________ 

Applicant/Tenant Name 

Applicant/Tenant Address City, State	 Zip Code 

The above person(s) has applied for tenancy/is a resident at ________________________________. As 

part of our processing we require verification of the household's income, expenses and other information 

related to eligibility. The individual has authorized below your release of the required information. The 

information you provide will be used only for the purpose of determining the household's eligibility for 

tenancy. We are required to complete our verification process in a short time period and would 

appreciate your prompt response. If you have any questions, please feel free to contact our office. 

Permission by: ______________________________________________________________________ 

(Applicant) (Date) 

Please complete the section below and return it in the enclosed self-addressed stamped envelope. 

(Please mail rather than have the above individual hand deliver.) Thank you in advance for your prompt 

attention. 

Sincerely, 

(Apartment Manager) 

TO BE COMPLETED BY INSTITUTION 

CHECKING ACCOUNT 

Account Number(s) Average 6 Month Balance(s) Interest Rate, If Any 

__________________ $ ________________________ 

____________________% 

__________________ $ ________________________ 

____________________% 

__________________ $ ________________________ 

____________________% 

F-3
 
________________________________________ _______________________________________ 

________________________________________ _______________________________________ 

________________________________________ _______________________________________ 

________________________________________ _______________________________________ 

ASSET VERIFICATION 

PAGE 2 

SAVINGS ACCOUNT 

Present Account Annual Interest Withdrawal 

Account Number(s) Balance(s) Rate Penalty 

__________________ $______________ ___________% __________ 

__________________ $______________ ___________% __________ 

__________________ $______________ ___________% __________ 

CERTIFICATE OF DEPOSIT 

Present Account Annual Interest Withdrawal 

Account Number(s) Balance(s) Rate Penalty 

__________________ $______________ ___________% __________ 

__________________ $______________ ___________% __________ 

__________________ $______________ ___________% __________ 

TRUST 

Value of Trust Fund Administered: $ __________________________
 

Anticipated Amount of Income to be earned by
 

Trust over next 12 months: $ __________________________
 

PROPERTY 

Value of Equity in Real Property	 $ __________________________ 

I certify that the above information is true and correct. 

Name of Official	 Title of Official 

Name of Institution	 Signature 

Address	 Date 

City, State, Zip Code	 Telephone Number 

WARNING:	 Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false 

statements or misrepresentations to any Department or Agency of the United States as to any 

matter within its jurisdiction. 

F-4
 
_________________________________________ ___________________________ 

_________________________________________ ___________________________

TENANT INCOME VERIFICATION FORM
 

Documentation of Telephone Verification 

Tenant Name: ______________________________ Date: ________________ 

Address: ______________________________ 

_____________________________________________ has applied for residency/is a resident at 

_______________________________________. This form documents employer's verification of his/her 

employment and gross annual income. 

INCOME REPORT BY: 

Anticipated Gross Income for the Next Twelve Months 

Hourly $____________	 Weekly $____________ 

No. of hours per week_____ 

Bi-weekly $____________	 Monthly $____________ 

Overtime: Average per $____________ $____________ $_____________ 

Day Week Month 

Tips, Commissions, Bonuses: 

Average per $____________ $____________ $_____________ 

$__________ 

Day Week Month 

Year 

- or ­

Total anticipated gross annual income for the next twelve months (including tips, bonuses or overtime 

if applicable) 

$_________________________. 

Name of Employer	 Date and Time 

_________________________________________ (________)__________________ 

Contact Person Telephone 

Title Management Staff (Signature) 

WARNING:	 Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false 

statements or misrepresentations to any Department or Agency of the United States as to any 

matter within its jurisdiction. 

F-5
 
FDIC
 

AFFORDABLE HOUSING PROGRAM
 

TENANT INCOME CERTIFICATION
 

PART I: SUMMARY OF HOUSEHOLD INCOME DATA 

1. Name (Last, First) 

A. 

2. Household 3. Check one: 

_Initial Certification 

B. _Recertification 

C. 

D. 

A. Size B. VLI _ 

LI _ 

OI _ 

A. Assets: 

Household 

Member Asset Description Total Cash Value 

Income from Assets 

A. 

4. Total Net Value of Assets 4. $...................... 

5. Total Actual Asset Income 5. $.................... 

6. If line 4 is greater than $5,000, multiply line 4 by passbook savings rate and enter result 

here; otherwise, leave blank. 

Passbook savings rate = _________________% 6. $.................... 

B. Anticipated Annual Income: 

Household 

Member 

a. Wages/ 

Salaries 

b. Benefits/ 

Pensions 

c. Public 

Assistance 

d. Other Income e. Asset Income 

A. 

Enter the greater of 

lines 5 or 6 in box e. 

B. 

C. 

D. 

7. Totals a. b. c. d. e. 

8. Enter total of items 7a. through 7e. 

This is Annual Income 8. $................... 

F-6
 
_________________________________________________ __________________ 

__________________________________________________ __________________ 

__________________________________________________ __________________ 

PART II: TENANT CERTIFICATION 

I/We certify that the information presented in Part I of this form is true and complete to the best of my/our 

knowledge and belief. I/We consent to the disclosure of such information to FDIC and/or the agency designated 

to monitor AHP program compliance. I/We understand that this certification is a part of the application process 

and does not guarantee occupancy. 

(SIGNATURE - HEAD OF HOUSEHOLD) DATE 

(SIGNATURE - SPOUSE/CO-HEAD OF HOUSEHOLD) DATE 

PART III OWNER/AGENT CERTIFICATION 

Based on the income information provided by the household and verified by me or my authorized agent, I certify 

that the household identified above is a(n): 

_ Very Low-Income (VLI) Household based on the current applicable definitions published by the U.S. 

Department of Housing and Urban Development. 

_ Lower Income (LI) Household based on the current applicable definitions of a low-income household 

published by the U.S. Department of Housing and Urban Development, OR qualifies as a LI household 

because the household income upon recertification is not greater than 140 percent of the current applicable 

lower income limit. 

_ Over-Income (OI) Household which exceeds the income standards for low-income households published by 

the U.S. Department of Housing and Urban Development, AND whose income is greater than 140 percent 

of the current applicable lower income limit. 

(OWNER/AUTHORIZED AGENT) DATE 

PART IV: TO BE COMPLETED BY MANAGEMENT STAFF 

Property: Contract Rent: $ 

Apt. #: # BR: Prepared by: 

Lease Date: Applicable LI Limit: 

Recertification Date: Applicable VLI Limit: 

WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false 

statements or misrepresentations to any Department or Agency of the United States as to any matter within its 

jurisdiction. 

F-7