TENANT INCOME CERTIFICATION QUESTIONNAIRE

One Form per Adult Member of the Household

NAME: TELEPHONE NUMBER:

_____________________________________ ( )_______________________
Initial Certification
Re-Certification Unit # _______________________
Other

I am a new household member who has occupied/will occupy unit on: __________

INCOME INFORMATION MONTHLY

Yes No GROSS INCOME
1. I am self-employed (list nature of self employment) (use adjusted net
income for self-
employment only)
__________________________________________ $ ____________
2. I have a job/have been offered employment and receive/will
receive wages, salary, overtime pay, commissions, fees,
tips, bonuses, and/or other compensation:

List the businesses and/or companies that pay you:

Name of Employer:
1. ________________________________________ $ ____________
2. ________________________________________ $ ____________
3. ________________________________________ $ ____________
3. I receive cash contributions of gifts including rent or utility
payments, on an ongoing basis from persons not living with
me. $ ____________
4. I receive unemployment benefits.
$ ____________
5. I receive Veteran's Administration, GI Bill, or
National Guard/Military Benefits/Income
$ ____________
6. I receive Social Security payments.
$ ____________
7. The household receives unearned income from family
members age 17 or under (example: Social Security, Trust
Fund disbursements, etc.) $ ____________
8. I receive Supplemental Security Income (SSI)
$ ____________

CA Tax Credit Allocation Committee

Page 1 of 5 Tenant Income Certification Questionnaire (Updated July 2022)
 TENANT INCOME CERTIFICATION QUESTIONNAIRE
One Form per Adult Member of the Household
Yes No
9. I receive disability, EDD paid family leave, EDD disability
insurance, or death benefits other than Social Security. $ ____________
10. I receive Public Assistance Income (examples: TANF,
CalWorks, CAPI, AFDC, GA/GR)

*Do not include CalFresh, SNAP, Food Stamps $ ____________

11. I am entitled to receive child support payments (court Total amount of
ordered or parental agreement) support received:

I am currently receiving child support payments

If yes, from how many persons do you receive support?
n/a ________ $ ____________
I am not currently receiving support, but I am making
efforts to collect child support owed to me. List efforts being
made:
___________________________________________
___________________________________________
___________________________________________
12. I am entitled to receive alimony or spousal support Total amount of
payments (court ordered or divorce agreement) support received:

I am currently receiving alimony/spousal support payments

If yes, from how many persons do you receive support?
n/a ________ $ ____________
I am not currently receiving support, but I am making
efforts to collect alimony or spousal support owed to me.
List efforts being made:
___________________________________________
___________________________________________
___________________________________________
13. I receive periodic payments from trusts, annuities,
inheritance, retirement funds or pensions, insurance
policies, or lottery winnings.

If yes, list sources:

___________________________________________ $ ____________
___________________________________________ $ ____________

CA Tax Credit Allocation Committee

Page 2 of 5 Tenant Income Certification Questionnaire (Updated July 2022)
 TENANT INCOME CERTIFICATION QUESTIONNAIRE
One Form per Adult Member of the Household
Yes No
14. I receive income from real or personal property. (use net earned
income)
$ ____________
15. I receive student financial aid (public/private, exclude loans)
Subtract cost of tuition from aid received

* For households receiving Section 8 assistance only $ ____________

16. Are any of the above noted income sources (including List Income Source:
Social Security, wages, unemployment, public assistance,
disability, etc.) , currently being received as _____________
a Debit Visa or MC? _____________
17. Do you anticipate receiving or have you applied for any List Income Source:
income source that will begin in the next 12 months? _____________
_____________

ASSET INFORMATION
Yes No Interest Rate Current Value
18. I have a checking account(s).
If yes, list bank(s)
1. ______________________________ ________% $ ____________
2. ______________________________ ________% $ ____________
19. I have a savings account(s).
If yes, list bank(s)
1. ______________________________ ________% $ ____________
2. ______________________________ ________% $ ____________
20. I have funds on an EBT card, Current Balance:
Debit Visa, or Debit MC
$ ____________
21. I have available funds held in a payment
service account, such as Venmo, PayPal,
Skrill, etc.

Source:
________________________________ $ ____________
________________________________ $ ____________

CA Tax Credit Allocation Committee

Page 3 of 5 Tenant Income Certification Questionnaire (Updated July 2022)
 TENANT INCOME CERTIFICATION QUESTIONNAIRE
One Form per Adult Member of the Household
Yes No Interest Rate Current Value
22. I have a revocable trust(s)

If yes, list bank(s)

1. ______________________________ ________% $ ____________
2. ______________________________ ________% $ ____________
23. I own real estate.
If yes, provide description:
1. ______________________________ $ ____________
2. ______________________________ $ ____________
24. I own crypto currency such as Bitcoin, Average Change
Litecoin, Ethereum, etc. over a 3 month
If yes, list type: period:
1. ______________________________ ________% $ ____________
2. ______________________________ ________% $ ____________
25. I own stocks, bonds, or treasury bills. Rate of return or
If yes, list sources/bank names 3 month average:
1. ______________________________ ________% $ ____________
2. ______________________________ ________% $ ____________
26. I have Certificates of Deposit (CD) or
Money Market account(s).
If yes, list sources/bank names
1. ______________________________ ________% $ ____________
2. ______________________________ ________% $ ____________
27. I have an IRA, lump sum pension,
Keogh account, or 401K.
If yes, list bank(s):
1. ______________________________ ________% $ ____________
2. ______________________________ ________% $ ____________
28. I have a life insurance policy with a
cash/surrender value.

If yes, how many policies? ________ $ ____________

29. I have disposed of assets (i.e. gave
away money/assets) for less than the
fair market value in the last 2 years.
If yes, list items and date disposed:
1. ______________________________ $ ____________
2. ______________________________ $ ____________

CA Tax Credit Allocation Committee

Page 4 of 5 Tenant Income Certification Questionnaire (Updated July 2022)
 TENANT INCOME CERTIFICATION QUESTIONNAIRE
One Form per Adult Member of the Household

30. I have cash on hand in excess of $250.

$ ____________

Yes No STUDENT ELIGIBILITY

I am a part-time student
I am a full-time student (Example: K-12, College, Trade School, etc.)
Does the entire household consist of people who are currently full-time students?
Does the entire household consist of people who are either currently a full time
student or were a full-time student for 5 months or more in the current calendar
year?
Does your household anticipate becoming an all full-time student household in
the next 12 months?
Yes No If you answered yes to any of the previous 5 questions, are you:
Receiving assistance under Title IV of the Social Security Act (AFDC, TANF,
CalWorks - not SSA/SSI)
Enrolled in a job training program receiving assistance through the Job Training
Participation Act (JTPA), Workforce Investment Act (WIA), or other similar
federal, state, or county government program
Married and filing (or are entitled to file) a joint tax return (please provide
copy of marriage certificate or tax return)
Single Parent with a dependent child(ren) and neither you or your child(ren) are
dependents of another individual
Previously enrolled in the Foster Care Program (currently age 18-24)

Under penalties of perjury, I certify that the information presented on this form is true
and accurate to the best of my knowledge. The undersigned further understands that
providing false representations herein constitutes an act of fraud. False, misleading or
incomplete information will result in the denial of application or termination of the lease
agreement.

_________________________________________
Printed Name of Applicant / Tenant

_________________________________________ _______________
Signature of Applicant / Tenant Date

_________________________________________ _______________
Witnessed by (Signature of Owner Representative) Date
CA Tax Credit Allocation Committee
Page 5 of 5 Tenant Income Certification Questionnaire (Updated July 2022)