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Je TOTAL HOUSEHOLD INCOME : List ALL money earned or received by everyone in your household. This ncludes money from Wages, Sel&Employment, Child Support, Cash Contributions, Social Security, SSI Income, Workman ' s Compensation, Retirement Benefits, TANF, Veteran' s Benefits, income from Bank Accounts, Alimony, Zental Property Income, Stock Dividends, and all other income sources. Print $$$ Amount Wages/Wkly AFDC/ TANF Child SS/SSI Other Income Support HEAD ( SELF ) [II . ASSETS : 1 . Do you or does any household member own or receive any interest for real estate, boats, mobile homes? ❑ Yes ❑ No Have you sold any real estate in the past 2 years? ❑ Yes ❑ No ? . Do you have any Stocks, Bonds or Certificates of Deposits? ❑ Yes ❑ No 3 . Do you have any Bank Accounts? ❑ Yes ❑No If Yes, provide Name of Bank : t . Do you drive a car? ❑ Yes ❑ No Do you own a car? ❑ Yes ❑ No > . Does anyone outside your household pay any of your bills or give you money? ❑ Yes ❑ No If Yes, Explain : i . Have you or any other adult member ever used any Name(s) or Social Security Number(s) other than the one you are currently using? ❑ Yes ❑No If Yes , Explain . 7 . Have you or has anyone in your household ever been arrested, charged or convicted of any crime other than traffic violations? ❑ Yes F1No If Yes, Explain . 3 . Have you ever committed any fraud in a Federal Assisted Housing Program or been requested to repay money for knowingly misrepresenting information for such housing programs? ❑ Yes QNo If Yes, Explain . WARNING ! ! ! ! Title 18 , Section 1001 of the United States Code, states that a person is guilty of a felony for cnowingly and willingly make false or fraudulent statements to any department or agency of the United States . do hereby swear and attest that all of the information above regarding family composition, income and assets are rue and correct. I also understand that any increases in income or change in family composition must be reported to he Indian River County Housing Authority in writing within 10 days. signature (Head of Household) . Date . signature (Spouse/Co-Tenant/Other Adult) : Date : ,urrent Telephone Number :