Household Information
Indicate all names of individuals in this category
Indicate all names of individuals in this category
Indicate all names of individuals in this category
Ethnicity of Household Members
Race of Household Members
Seniors
Indicate all names of individuals in this category
Health Concerns for the household
Household members with disabilities
Indicate all names of individuals in this category
Indicate all names of individuals in this category
Indicate all names of individuals in this category
Employment
Household Veterans
Students & Children
Indicate all names of children in this category
Indicate all names of children in this category
Indicate all names of children in this category
Indicate all names of children in this category
This is a written statement from the beneficiary documenting the definition used to determine “Annual Income,” which is the gross amount of income of all adult household members (at the time of admission) that is anticipated to be received during the coming 12-month period and includes providing the relevant characteristics of each household member. “Annual income” is defined at 24 CFR Part 5.609 and includes but is not limited to, the full amount of wages and salaries before any payroll deductions, overtime pay, commissions, fees tips or bonuses, and other compensation for personal services, interest and dividends, net income from the operations of a business or from real or personal property, the full amount of periodic payments such as social security, annuities, pensions, payments, in lieu of earnings such as unemployment or disability compensation, workers comp, severance pay, welfare assistance, alimony, child support, etc. It does not include food stamps or Section 8.
This is a written statement from the beneficiary documenting the definition used to determine “Annual Income,” which is the gross amount of income of all adult household members (at the time of admission) that is anticipated to be received during the coming 12-month period and includes providing the relevant characteristics of each household member. “Annual income” is defined at 24 CFR Part 5.609 and includes but is not limited to, the full amount of wages and salaries before any payroll deductions, overtime pay, commissions, fees tips or bonuses, and other compensation for personal services, interest and dividends, net income from the operations of a business or from real or personal property, the full amount of periodic payments such as social security, annuities, pensions, payments, in lieu of earnings such as unemployment or disability compensation, workers comp, severance pay, welfare assistance, alimony, child support, etc. It does not include food stamps or Section 8.
This is a written statement from the beneficiary documenting the definition used to determine “Annual Income,” which is the gross amount of income of all adult household members (at the time of admission) that is anticipated to be received during the coming 12-month period and includes providing the relevant characteristics of each household member. “Annual income” is defined at 24 CFR Part 5.609 and includes but is not limited to, the full amount of wages and salaries before any payroll deductions, overtime pay, commissions, fees tips or bonuses, and other compensation for personal services, interest and dividends, net income from the operations of a business or from real or personal property, the full amount of periodic payments such as social security, annuities, pensions, payments, in lieu of earnings such as unemployment or disability compensation, workers comp, severance pay, welfare assistance, alimony, child support, etc. It does not include food stamps or Section 8.
This is a written statement from the beneficiary documenting the definition used to determine “Annual Income,” which is the gross amount of income of all adult household members (at the time of admission) that is anticipated to be received during the coming 12-month period and includes providing the relevant characteristics of each household member. “Annual income” is defined at 24 CFR Part 5.609 and includes but is not limited to, the full amount of wages and salaries before any payroll deductions, overtime pay, commissions, fees tips or bonuses, and other compensation for personal services, interest and dividends, net income from the operations of a business or from real or personal property, the full amount of periodic payments such as social security, annuities, pensions, payments, in lieu of earnings such as unemployment or disability compensation, workers comp, severance pay, welfare assistance, alimony, child support, etc. It does not include food stamps or Section 8.
This is a written statement from the beneficiary documenting the definition used to determine “Annual Income,” which is the gross amount of income of all adult household members (at the time of admission) that is anticipated to be received during the coming 12-month period and includes providing the relevant characteristics of each household member. “Annual income” is defined at 24 CFR Part 5.609 and includes but is not limited to, the full amount of wages and salaries before any payroll deductions, overtime pay, commissions, fees tips or bonuses, and other compensation for personal services, interest and dividends, net income from the operations of a business or from real or personal property, the full amount of periodic payments such as social security, annuities, pensions, payments, in lieu of earnings such as unemployment or disability compensation, workers comp, severance pay, welfare assistance, alimony, child support, etc. It does not include food stamps or Section 8.
This is a written statement from the beneficiary documenting the definition used to determine “Annual Income,” which is the gross amount of income of all adult household members (at the time of admission) that is anticipated to be received during the coming 12-month period and includes providing the relevant characteristics of each household member. “Annual income” is defined at 24 CFR Part 5.609 and includes but is not limited to, the full amount of wages and salaries before any payroll deductions, overtime pay, commissions, fees tips or bonuses, and other compensation for personal services, interest and dividends, net income from the operations of a business or from real or personal property, the full amount of periodic payments such as social security, annuities, pensions, payments, in lieu of earnings such as unemployment or disability compensation, workers comp, severance pay, welfare assistance, alimony, child support, etc. It does not include food stamps or Section 8.
This is a written statement from the beneficiary documenting the definition used to determine “Annual Income,” which is the gross amount of income of all adult household members (at the time of admission) that is anticipated to be received during the coming 12-month period and includes providing the relevant characteristics of each household member. “Annual income” is defined at 24 CFR Part 5.609 and includes but is not limited to, the full amount of wages and salaries before any payroll deductions, overtime pay, commissions, fees tips or bonuses, and other compensation for personal services, interest and dividends, net income from the operations of a business or from real or personal property, the full amount of periodic payments such as social security, annuities, pensions, payments, in lieu of earnings such as unemployment or disability compensation, workers comp, severance pay, welfare assistance, alimony, child support, etc. It does not include food stamps or Section 8.
This is a written statement from the beneficiary documenting the definition used to determine “Annual Income,” which is the gross amount of income of all adult household members (at the time of admission) that is anticipated to be received during the coming 12-month period and includes providing the relevant characteristics of each household member. “Annual income” is defined at 24 CFR Part 5.609 and includes but is not limited to, the full amount of wages and salaries before any payroll deductions, overtime pay, commissions, fees tips or bonuses, and other compensation for personal services, interest and dividends, net income from the operations of a business or from real or personal property, the full amount of periodic payments such as social security, annuities, pensions, payments, in lieu of earnings such as unemployment or disability compensation, workers comp, severance pay, welfare assistance, alimony, child support, etc. It does not include food stamps or Section 8.
Please review if your household income is at or below these numbers, which will allow you to participate in additional programs:
- 2020 ANNUAL HOUSEHOLD INCOME GUIDELINES (185% of poverty)
(more than 8 add $9,528.00 for each additional person)
| Family Size |
Income |
| 1 |
$27,158.00 |
| 2 |
$36,686.00 |
| 3 |
$46,213.00 |
| 4 |
$55,740.00 |
| 5 |
$65,268.00 |
| 6 |
$74,796.00 |
| 7 |
$84,323.00 |
| 8 |
$93,851.00 |
WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.
