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Attachment D <br />EXHIBIT BÎ2 <br />FORM OF INCOME RECERTIFICATION <br />Effective Date: _____________________ <br />INCOME CERTIFICATION <br /> Move-in Date: _____________________ <br /> (MM/DD/YYYY) <br /> Initial Certification Recertification Other* _________ <br />*Transfer from Unit: ___________ <br />PART I Î DEVELOPMENT DATA <br />Property Name: County: <br />Unit Number: # Bedrooms: <br />PART II. HOUSEHOLD COMPOSITION <br />Relationship to <br />HH Last 4 digits of Social <br />First Name & Middle <br />Date of Birth <br />Last Name Head <br />(MM/DD/YYYY) <br />Mbr # Initial Security Number <br />of Household <br /> HEAD <br />1 <br /> <br />2 <br /> <br />3 <br /> <br />4 <br /> <br />5 <br /> <br />6 <br /> <br />7 <br />PART III. GROSS ANNUAL INCOME (USE ANNUAL AMOUNTS) <br />HH (A) (B) (C) (D) <br />Mbr # Employment/Wages Soc. Security/Pensions Public Assistance Other Income <br /> <br /> <br /> <br /> <br /> <br /> <br />TOTALS <br />$ $ $ $ <br />Add totals from (A) through (D) above TOTAL INCOME (E): $ <br />PART IV. INCOME FROM ASSETS <br />HH (F) (G) (H) (I) <br /> Mbr # Type of Asset C/I Cash Value of Asset Annual Income from Asset <br /> <br /> <br /> <br />TOTALS: $ $ <br />TOTAL INCOME FROM ASSETS (K) <br />$ <br />(L) Total Annual Household Income from all Sources \[Add (E) + (K)\] $ <br /> <br /> <br /> B-2-1 <br />12519391v3 <br /> <br />