Income Statement

Income Statement
You must list all sources of income. Please check yes or no for each income listed below. If you check yes, indiciate the monthly amount and who/where you receive this income from (employer, social services, family, etc.)

Do you receive income from employment?*

YesNo

MONTHLY income amount from employment*

Name of person or place you receive employment income from*

Do you receive MFIP (Minnesota Family Investment Program) through county assistance?*

YesNo

MONTHLY amount received from MFIP*

Name of county you receive MFIP from*

Do you receive CA (Cash Assistance) through county assistance?*

YesNo

MONTHLY amount received from CA*

Name of county you receive CA from*

Do you receive GA (General Assistance) through county assistance?*

YesNo

MONTHLY amount received from GA*

Name of county you receive GA from*

Do you receive HG (Housing Grant) through county assistance?*

YesNo

MONTHLY amount received from HG*

Name of county you receive HG from*

Do you receive MSA (Minnesota Supplemental Aid) through county assistance?*

YesNo

MONTHLY amount received from MSA*

Name of county you receive MSA from*

Do you receive DWP (Diversionary Work Program) through county assistance?*

YesNo

MONTHLY amount received from DWP*

Name of county you receive DWP from*

Do you receive child support (court order or mutual agreement)?*

YesNo

MONTHLY amount received from child support*

Is the child support court ordered or a mutual agreement?*

Court OrderedMutual Agreement

Name of county child support is ordered through*

Name of person you receive child support from*

Do you receive Social Security, SSI, SSDI, or RSDI?*

YesNo

MONTHLY amount of SS, SSI, SSDI, or RSDI received*

If your household receives more than one, enter the TOTAL amount

Name of place/person you receive this income from*

Do you receive income from pension (PERA, railroad, etc.)?*

YesNo

MONTHLY amount received from pension*

Name of place you receive pension from*

Do you receive veteran's compensation?*

YesNo

MONTHLY amount received from veteran's compensation*

Name of place you receive veteran's compensation from*

Are you self-employed or do you receive odd jobs?*

YesNo

MONTHLY amount received from self-employment or odd jobs*

Name of place/person you receive this income from*

Do you receive unemployment benefits or severance pay?*

YesNo

MONTHLY amount of unemployment benefits or severance pay received*

Name of person/place you receive this income from*

Do you receive alimony or spousal maintenance?*

YesNo

MONTHLY amount received from alimony or spousal maintenance*

Name of place/person you receive this income from*

Do you receive payments from annuities or life insurance?*

YesNo

MONTHLY amount received from annuities or life insurance*

Name of place/person you receive this income from*

Do you receive payments from inheritance, lottery winnings, or insurance settlment?*

YesNo

MONTHLY amount received*

Name place/person you receive this income from*

Do you receive income from rental property?*

YesNo

MONTHLY amount received*

Name of place/person you receive this income from*

Do you receive income from babysitting or providing child care?*

YesNo

MONTHLY amount received*

Name of person/place you receive this income from*

Do you receive income from cleaning?*

YesNo

MONTHLY amount received*

Name of person/place you receive this income from*

Do you receive income from doing handyman/lawncare/snow removal services?*

YesNo

MONTHLY amount received*

Name of person/place you receive this income from*

Are you an independent sales consultant? (Tupperware, Mary Kay, Zyia, etc.)*

YesNo

MONTHLY amount received*

Name of person/place you receive this income from*

Do you receive money from family and/or friends for food, clothing, household goods, etc.?*

YesNo

MONTHLY amount received*

Name of person/place you receive this income from*

Do you receive regular utility assistance for rent, cellphone, utilities, or other living expenses?*

YesNo

MONTHLY amount received*

Name of person/place you receive this income from*

I understand that when my household starts receiving income, it must be reported to the housing authority within 10 business days. I understand that any misrepresentation of information or failure to disclose information requested on this worksheet may disqualify me from consideration for admission or participation in any housing assistance program.

I, Full Name* , certify that there is no income coming into my household, other than noted in this Income Statement.

Signature*

Date*

Date

Warning - Title 18 US Code Section 1001 states that a person is guilty of a felony for knowinly and willingly making a false or fradulent statement to any department agency of the United States. If this form contains false or incomplete information, you may be required to repay all overpaid rental assistance you received; fined up to $10,000; imprisoned for up to 5 years; and/or prohibited from receiving future assistance.