FDIC
 

AFFORDABLE HOUSING PROGRAM
 

TENANT INCOME CERTIFICATION
 

PART I: SUMMARY OF HOUSEHOLD INCOME DATA 

1. Name (Last, First) 

A. 

B. 

2. Household 3. Check one: 

Initial Certification 

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. $................... 

PART II: TENANT CERTIFICATION 

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_________________________________________________ __________________ 

__________________________________________________ __________________ 

__________________________________________________ __________________ 

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 

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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. 

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FDIC 

TENANT INCOME CERTIFICATION 

Instructions 

GENERAL.	 This form is to be completed for all initial certifications and recertification of 

households who are designated to meet the Total and VLI Set-Asides for 

AHDP properties (VLI and LI tenants) 

PART I. SUMMARY OF HOUSEHOLD INCOME DATA 

Item 1. Name List all household members who will be occupying 

this unit. 

Item 2A. Household Size Identify the total number of persons occupying the 

unit. 

Item 2B. Household Designation Indicate the income category as designated in Part 

III: Very Low-Income (VLI); Lower Income (LI); or 

Over-Income (OI). 

Item 3. Certification/ 

Recertification 

Check whether the action being processed is an 

initial certification or an annual recertification. 

A. Assets: As prescribed in the Compliance Manual, verify 

and list the assets owned by this household. 

Indicate who owns the asset by listing the 

corresponding family member letter used in 

Item #1. Describe the asset; indicate the current 

market value; and estimate the income from the 

asset. 

If the number of assets exceed the lines available, 

use additional sheets. Reference the additional 

sheets and include the totals for Cash Value and 

Income from Assets from these sheets as a single 

line. 

Item 4. Total Net Family Assets	 Enter the total cash value of all of the assets in this 

column. 

Item 5.	 Total Actual Asset Provide the total actual income anticipated from 

Income the assets listed. 

Item 6. Imputed Income From If the total in item 4 exceeds $5,000, multiply line 4 

Assets by the HUD approved passbook savings rate. To 

obtain up-to-date information on the passbook rate 

in use, contact the monitoring agency. 

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B. Anticipated Annual Income As prescribed in the Compliance Manual, verify 

and list the gross amount of income anticipated by 

this household. Indicate who will be receiving this 

income by listing the corresponding family member 

letter used in Item #1 and indicate the gross 

amount in the appropriate column. 

If the number of household members with income 

exceeds the lines available, use additional sheets.

 Reference the additional sheets and include the 

totals for each type of income on the open line. 

Item 7. Total income, a - e	 Line 7, a - e, enter total income by source, 

including assets. 

Item 8. Annual income	 This is the total annual income of this household. 

Compare to the applicable AHP income limits to 

determine eligibility. 

PART II TENANT CERTIFICATION 

The adult family members must sign Part II certifying the accuracy and completeness of 

the information provided in Part I of this form. 

PART III OWNER/AGENT CERTIFICATION 

Indicate the appropriate income designation (e.g., Very Low-Income; Lower Income; or 

Over-Income (for recertified tenants only, income exceeding 140% of lower income limits). 

Agents must sign and date the certification. 

PART IV ADDITIONAL INFORMATION 

Fill in the appropriate information. 

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