INCOME CERTIFICATION QUESTIONNAIRE for HOME/CDBG/CDBG-D Programs (*NOTE: A separate questionnaire must be completed by each adult member of the household) Name* First Last Email* Phone*How many people will live in the household?* What are their names and ages?* Do you or will you receive regular income from a job, jobs, or personal services?* Yes No Comments Do you or will you receive overtime pay?* Yes No Comments Do you or will you receive tips or bonuses?* Yes No Comments Do you own a business?* Yes No How much net income do you receive from it?* Do you or will you receive interest, dividends, or other net income of any kind from real or personal property?* Yes No Comments Do you or will you receive Social Security, annuities, insurance policies, retirement funds, pensions, disability or death benefits, and other similar types of periodic receipts?* Yes No Comments Do you or will you receive unemployment and disability compensation, worker's compensation, or severance pay?* Yes No Comments Do you or will you receive periodic and determinable allowances such as alimony or child support payments?* Yes No Comments Do you or will you receive regular contributions or gifts from organizations or from persons who will not reside in the dwelling?* Yes No Comments Do you or will you receive regular pay, special pay, or allowances as a member of the Armed Forces?* Yes No Comments Do you have a savings account?* Yes No Comments Do you have a checking account?* Yes No Comments Do you have a safe deposit box?* Yes No Comments Do you have a revocable trust?* Yes No Comments Do you own rental property or have other capital investments?* Yes No Comments Do you own stocks, bonds, Treasury bills, certificates of deposit, mutual funds, or money market accounts?* Yes No Comments Do you have any individual retirement accounts, 401(K)s, or Keogh accounts?* Yes No Comments Do you have any retirement or pension funds?* Yes No Comments Do you have a life insurance policy available before death?* Yes No Comments Do you have any personal property held as an investment, such as gems, jewelry, coin collections, antique cars, etc.?* Yes No Comments Have you received any lump sum or one-time receipts, such as inheritances, capital gains, lottery winnings, victim's restitution, insurance settlements, or other amounts not intended as periodic payments?* Yes No Comments Do you have any mortgages or deeds of trust held in your name?* Yes No Comments Δ
