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Attachment D <br />INSTRUCTIONS FOR COMPLETING <br />TENANT INCOME CERTIFICATION <br />This form is to be completed by the owner or an authorized representative. <br />Part I Î Development Data <br />Check the appropriate box for Initial Certification (move-in), Recertification (annual recertification), or Other. If <br />Other, designate the purpose of the recertification (i.e., a unit transfer, a change in household composition, or <br />other state-required recertification). <br /> <br />Move-in Date Enter the date the tenant has or will take occupancy of the unit. <br /> <br />Effective Date Enter the effective date of the certification. For move-in, this should be the move-in date. <br />For annual recertification, this effective date should be no later than one year from the <br />effective date of the previous (re)certification. <br /> <br />Property Name Enter the name of the development. <br /> <br />County Enter the county (or equivalent) in which the building is located. <br /> <br />BIN # Enter the Building Identification Number (BIN) assigned to the building (from IRS Form <br />8609). <br /> <br />Address Enter the unit number. <br /> <br />Unit Number Enter the unit number. <br /> <br /># Bedrooms Enter the number of bedrooms in the unit. <br /> <br />Part II Î Household Composition <br /> <br />List all occupants of the unit. State each household memberÓs relationship to the head of the household by using <br />one of the following coded definitions: <br /> <br />H Head of household S Spouse <br />A Adult co-tenant O Other family member <br />C Child F Foster child <br />L Live-in caretaker N None of the above <br /> <br />Enter the date of birth, student status, and Social Security number or alien registration number for each occupant. <br /> <br />If there are more than seven occupants, use an additional sheet of paper to list the remaining household members <br />and attach it to the certification. <br /> <br /> B-1-5 <br />12519391v3 <br /> <br />