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Attachment D HOUSEHOLD CERTIFICATION & SIGNATURES The information on this form will be used to determine maximum income eligibility. I/we have provided for each person(s) set forth in Part II acceptable verification of current anticipated annual income. I/we agree to notify the landlord immediately upon any member of the household moving out of the unit or any new member moving in. Under penalties of perjury, I/we certify that the information presented in this Certification is true and accurate to the best of my/our knowledge and belief. The undersigned further understands that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination of the lease agreement. Signature (Date) Signature (Date) Signature (Date) Signature (Date) PART V. RENT A. Tenant Paid Rent: $ B. Rent Assistance: $ C. Other non-optional charges and mandatory fees: $ D. Gross Rent For Unit (See Instructions): $ PART VI. DETERMINATION OF INCOME ELIGIBILITY TOTAL ANNUAL HOUSEHOLD Household Meets RECERTIFICATION ONLY: $ INCOME FROM ALL SOURCES Income Restriction From Item (L) on page 1 at: Current Income Limit x 140% 60% 50% 40% 30% $ ___________________________ Current Income Limit per Family Size: $ __% Household income exceeds 140% at recertification: Yes No Household Income at Move-in $ Household Size at Move-in: ______ SIGNATURE OF OWNER/REPRESENTATIVE Based on the representations herein and upon the proofs and documentation required to be submitted, the individual(s) named in Part II of this Tenant Income Certification is/are eligible under the provisions of programÓs rules, regulations and the Land Use Restriction Agreement, to live in a unit in this Project. _____________________________________________ _____________ SIGNATURE OF OWNER/REPRESENTATIVE DATE B-2-2 12519391v3