Annual Income Review Sheet for Dhcr New York Real Property Law Section 421-M Program

New York Real Law 421-m(A)New Section 4/12/2012 York Property LAWNEWREAL PROGRAM PROPERTY 421-MINCOME REVIEW FOR DHCR SECTION ANNUAL SHEET YORK No. 14 13 12 11 10 9 8 7 6 5 4 3 2 1 First Name New StateDivision ofHousingand York Renewal Community New York Property Tax Law Property York Tax 421-m(A)Form Section New 25 Beaver Street New York,10004-2319 Street New NY 25 Beaver Web Site: Last Name www.nyshcr.org Relationship to Page Page Self (Head) Household Head ofHead 1 of 5 (MM/DD/YYYY) Date of Birth of Date Cell Phone (Cell # ) WorkPhone ( # ) # Home Phone ( ) Outside Country) US, (City State;If & Place of BirthPlace of Employed?               Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes One               Check ( Check No No No No No No No No No No No No No No  This MustThis Be Package By: Returned ReviewAnnual Income Month/Year: (Stick Label Here o ) r Print NamePrintAddress and r

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tenant(s) do toprovideout.tenant(s) them,Part then befilled want not III must IIPART New York Real Law 421-m(A)New Section 4/12/2012 York Property *** attach and3Bank C Self-Employment C-EZ of FederalAccount Form, **Must last Form completed notarized months’ Statementsor fromIncome Return Business 1040 and all to Tax Form with attachments it. Every is member * who household employed Part Part IncomeEarnedIII(A): Part Part Other III(C): Income Current /Self-EmployedPart Own III(B): Business First Name, Last Name, First

Must attach current from source the Must of most documentsincome its for type other received. First Name, LastName Name, First LastName Name, First Name : The tenant(s) will provide a certified copy of their federal tax return for themselves and for each adult member oftheir taxreturn forhousehold. themselveseachinformation federal and adultmember this or available the If isnot copyoftheir acertified will: Thetenant(s) provide Per $ Per $ Per $ Welfare Mustcomplete thissection household for areall members 18 who years or (includingemployedpart studyof and oldertime programs)age jobs/work Address of BusinessAddress Self of Employment / Owned must Per $ Per $ Per $

Mustcompletethissection any if receive fromin person(s)the income household other sources Security Social attach most 4 6 pay and the for current to consecutive stubs “Request completed Verification I Employment” and for form job.(Part of only), signed dated each / Must ifMust the complete household his/hersection person this any has in own business or is self-employed Employer’s and Name Per $ Per $ Per $ SSI Address Page Page Per $ Per $ Per $ 2 Pension of 5

Per $ Per $ Per $ Support Child Gross Salesfor Receipts or Past Three (3)Past Three Months Employer’s WorkTelephone No.Employer’s and Per $ Per $ Per $ Unemploy- Benefits ment Fax No. Per $ Per $ Per $ Adoption Income Past (3) Past Three Months Cost of Goods Sold Cost Goods for of Sold Per $ Per $ Per $ Foster Care Income Total Earned Year Total Previous (Gross W-2) from *** Per $ Per $ Per $ Expenses for Past for Expenses Dividends Three Months (3) Interest/ Specify AmountSpecify Per Annually) Weekly/Bi-Weekly/Monthly/Quarterly/ Per $ Per $ Per $ Compensation ** Workers’ Present Rate of PayPresent of Rate Unit is For Unit Used Business Rent Paid Subsidized Rent if (Gross) Per $ Per $ Per $ Amount Family or Third Party Help Per $ Per $ Per $ Source

Barcode Semi-Monthly/Monthly Weekly/Bi-Weekly/ Profit forThreeProfit Past * Specify One - Specify One (3) Months $ $ $ per Month per Stamps Food

income thoseadjustments as are on lines listed on 23-35 the Form. IRS 1040 First Name, Last Name Name,First Last New York Real Law 421-m(A)New Section 4/12/2012 York Property 90% ofAMI, than ofless household villagetaxassessor mayuse thetenant then which proofas townrequirement shall such inform or thecity, alternative. an toParts II IV:an the tenant(s)PART or income As III, housing has if household verifies alternative programand in which anotherlow-income, assistance income isparticipating an 4. 3. 2. 1. NO- YES for and income.For institution/company)name company,number interest shares dividend and stocks, market state of of held current value. Must last each three statements account principal,interest dividend clearly***** attach for (3) asset months’ with and income these must copies ****For all adjustment, you attach of prescriptions, invoices,cash as as checks bills well cancelled for of proof payment. Part AllowancePart ExpenseIII(D): Part Assets– III(E): Bank Accounts, LotteryStocks,Insurance, Winnings First Name,Last First PartIII(F): AssetsOther    

Name    

Do you or any household member own any other valuables such as gems, or jewelry youcoin other suchcollection. or as any own valuables Do any household member youvehiclesautomobiles, motor or any own(boats, Do any household motorcycles,etc.)? member in anyestate anysold real thetwoyears? last household member youHave or orhome? you have interestmobile or anyestate in any ownreal Do or an household member ( MARK CHECK PLACE ______Mustattachcopiesownership of documentssuch copy closing as andof statement you deed ifquestions 2 YES answer and to below1 Savings Acct. No. Bank NameBank Complete only the iffamilysection in this mustorder to eligibility meet to calculate theiradjustments gross Ifso,thisincome. mustlistfordeductionsgrosssection  ) IN APPROPRIATEBOX ) Adjustments Adjustments Checking Acct.No.Checking Bank Name Page Page 3 of 5

**** Completetable person(s)household the anyhave if type in any fromof and/or assetsincome assets***** If yes, Money Acct.Market No. please provide State, Borough, Block and Lot Numbers and date of transfer: ______Numbersdate Borough,Block State, Lot of and provide and please Bank NameBank If yes, Reasons for Adjustments Reasons

traceable. Also attach must copies previous Form (you receiveform your of year’s 1099 should this from financial If yes, If please provide State, Borough, Block and Lot Numbers: Borough,Block State, Lot ______provide and please If yes, If please state the make(s), model(s), year(s) and License plate number(s) for each: ______and plateeach: state year(s) License number(s) please the for make(s), model(s), state details of the items and current market value: ______itemscurrentmarketstate detailsofvalue: and the CD Account CD No. Bank Name Account Current No. & Value. Annuity, Insurance,IRA,etc. Annuity, Medical Expenses Not Otherwise Listed on IRS 1040FormMedical NotOtherwiseListedonIRS Expenses Name Name Firm/Brokerof Lottery Winnings.Lottery Stocks, Bonds, Funds,etc.Stocks,Bonds, Mutual market and if Value Acct. No.,

Barcode Name Name Issuer of any****** arecorrecttrueand that andI not or madefalse any haveknowingly willfully statement, informationorgiven false omitted income information in with review.connectionannual this Headof the DeclarationHousehold New under York Property Law Tax 421-M Section 1. New York Real Law 421-m(A)New Section 4/12/2012 York Property groundsinformationisforterminationinaccurate of or ofhousing assistanceterminationtenancy. that incomplete I false,or knowingly informationunderstand supplying may inaccurate punishable underfederal and/orcriminalIbe law. understand knowingly supplying thatorstate incomplete,false, and Criminal ActionsAdministrativeforInformationFalse am forcontinuedbenefitsI tocooperate insupplying participation, level know informationneeded verifyI todetermine circumstances.of required my my trueall eligibility and Cooperation or ofinformation,vacate lease. in theviolation the unit I haveI that reported certify any federalassistancehousing previous and anyowed. iswhether moneyor certify forthis not assistance I previousthat I any knowinglydid misrepresentnot commit fraud, any AssistanceReporting Prior Housing on andthat certifyentire truere-certification theinformationiscorrect.shown and all I the information on that certify provided family and composition,income,forhouseholdallowances items assets and accurate isand deductions, of to completethebestmy knowledge. I have reviewed this True CompleteInformationand Giving 3. 2.

YES NO- YES PartCertificationVI: Participant    Part V: V: Part

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DECLARATION mustanswer (You PERSONAL questions) ALL If yes, If for misrepresenting knowingly repaymoney orrequestedfor such ofcommittedfederallyto anyassisted program information been your ahousing member state fraudin youmunicipal, or Have or household youusing? Securityarecurrently household adult otherSocial number(s) membersthan any one other name(s) everused or youHave or INFORMATION FROM NUMBERS) STATEMENTPROVIDER CONTACT INCLUDING (MUST WITH ATTACH NOTARIZEDTHE FULL TELEPHONE outsideof anyone yourany bills ofDoes or household pay your give you money? ( MARK CHECK PLACE housing programs? housing explain: ______:

 ) IN APPROPRIATEBOX ) Page Page 4 of 5 If yes If : I statementsthatall declare income all andcontained in review annual this sheet/package attachments thereto , explain ______If yes, explain: ______

Barcode Name of Head Household of Name of (PRINT) ______New York Real Law 421-m(A)New Section 4/12/2012 York Property Adult ofSignature Other ______Date Signature of Other Adult of Signature Other of Signature of Head Household ______

______Page Page 5 of 5 D Date ate

Signature of Signature Spouse/Co-Head Date

______Signature Other Signature Date Other Date Adult of Adult of

______Signature of Other Adult of Signature Other Date

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