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  • Northwest Minnesota Multi-County HRA
    Main Office
    205 Garfield Ave | PO Box 128 | Mentor, MN 56736
    Phone: 218-637-2431 | Fax: 218-637-2433
    Satellite Office:
    1708 River Road NW | East Grand Forks, MN 56721
    Phone: 218-773-2371 | Fax: 218-773-9331

     

    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?*
  • Do you receive MFIP (Minnesota Family Investment Program) through county assistance?*
  • Do you receive CA (Cash Assistance) through county assistance?*
  • Do you receive GA (General Assistance) through county assistance?*
  • Do you receive HG (Housing Grant) through county assistance?*
  • Do you receive MSA (Minnesota Supplemental Aid) through county assistance?*
  • Do you receive DWP (Diversionary Work Program) through county assistance?*
  • Do you receive child support (court order or mutual agreement)?*
  • Is the child support court ordered or a mutual agreement?*
  • Do you receive Social Security, SSI, SSDI, or RSDI?*
  • Do you receive income from pension (PERA, railroad, etc.)?*
  • Do you receive veteran's compensation?*
  • Are you self-employed or do you receive odd jobs?*
  • Do you receive unemployment benefits or severance pay?*
  • Do you receive alimony or spousal maintenance?*
  • Do you receive payments from annuities or life insurance?*
  • Do you receive payments from inheritance, lottery winnings, or insurance settlment?*
  • Do you receive income from rental property?*
  • Do you receive income from babysitting or providing child care?*
  • Do you receive income from cleaning?*
  • Do you receive income from doing handyman/lawncare/snow removal services?*
  • Are you an independent sales consultant? (Tupperware, Mary Kay, Zyia, etc.)*
  • Do you receive money from family and/or friends for food, clothing, household goods, etc.?*
  • Do you receive regular utility assistance for rent, cellphone, utilities, or other living expenses?*

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

  • Date*
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  • 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.

  • Should be Empty: