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[I. TOTAL HOUSEHOLD INCOME : List ALL money earned or received by everyone in your household . This .ncludes money from Wages , Self-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 : [ . Do you or does any household member own or receive any interest for real estate , boats, mobile homes ? ❑ Yes F] 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 : 1 . 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 : ) . 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 ? E] Yes ❑No If Yes , Explain: 1 . Have you or has anyone in your household ever been arrested, charged or convicted of any crime other than traffic violations ? ❑ Yes ❑ No 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 ❑No If Yes , Explain : WARNING ! ! ! ! Title 18 , Section 1001 of the United States Code , states that a person is guilty of a felony for mowingly 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 :