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mylife122260
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Income and Asset Statement

The adult named below must complete AND sign this form even if there is no income
(Must be 18 years or older at time of signature)
Name Client # Date of Birth _
DECLARATION OF ACKNOWLEDGEMENT
Penalties for committing fraud: The United States Department of Housing and Urban Development (HUD) places a high
priority on preventing fraud. The following may occur if you provide information that you know is false or incomplete:
 Termination from the program  Imprisonment for up to five (5) years
 Repayment for overpaid rental assistance you received  Fine of up to $10,000
 Disqualification from receiving future assistance
By signing below I am certifying that I have completed the Income and Asset form and that the information I have given is
true and complete.
SIGNATURE_________________________________________________________ DATE ____________________

DO YOU OWN OR HAVE ANY OF THESE ASSETS? (In or out of the United States)
YES NO YES NO
Checking Account(s) House, Condo, Mobile Home, Real Estate
Savings / Money Market Account(s) Certificate of Deposit (CD) / Treasury Bills / Bonds
IRA (Individual Retirement Account) Whole Life Insurance Policies
Trust Fund Other: ________________

Bank Name_______________________________________ Type of Account_______________Account #______________________


Bank Name_______________________________________ Type of Account_______________Account #______________________
Bank Name_______________________________________ Type of Account_______________Account #______________________
YES NO
Have you disposed of any asset(s) for less than fair market value in the last 2 years?
Do you have any assets held jointly with another person? (Ex: Checking, Savings, real estate, etc.)

DO YOU RECEIVE INCOME FROM ANY OF THESE SOURCES?


 All income and assets must be reported for determination of continued program eligibility.
 Current verification is required for ALL household members (including minors) who receive income and/or benefits.
 Some income and/or benefits may not be included when your rent portion is calculated.
YES NO YES NO YES NO
Job / Wages Self Employment Tips or bonuses or commissions
SSI and/or SSA Unemployment Worker’s Comp / Disability
SSI for Minor Veterans Benefits Employment Training Program
TANF / CalWORKS Pensions / Retirement Annuities or non-revocable trust
General Assistance Child Support Income from rent or sale of property
Food Stamps Alimony Dividends/Payments from investments
Cash Gifts / Loans Adoptive Assistance Military Pay
Lump sum payment Foster Care / Kin Gap Other: ________________

Employer(s) Name____________________________________________________________Phone#__________________________
Address______________________________________________________ City______________________ Zip_________________
Employer(s) Name____________________________________________________________Phone#__________________________
Address______________________________________________________ City______________________ Zip_________________
Person providing support (Ex: Child Support, Alimony, Gifts/Loans):____________________________________________________
Phone#____________________________Address___________________________________________________________________
Person providing support (Ex: Child Support, Alimony, Gifts/Loans):____________________________________________________
Phone#____________________________Address___________________________________________________________________

OHA Form #290099 Income and Asset Statement Revised 6/2017 RX Month: _____

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