TENANT INCOME CERTIFICATION - Initial Certification

TENANT INCOME CERTIFICATION

 Initial Certification  Recertification  Other ____________

Effective Date: _____________________

Move-In Date: ______________________

(MM-DD-YYYY)

PART I - DEVELOPMENT DATA

County: _______________ TCAC#: BIN#:

If applicable, CDLAC#:

Property Name:

Address:

Unit Number:

# Bedrooms: Square Footage: ___________

PART II. HOUSEHOLD COMPOSITION

 Vacant (Check if unit was vacant on December 31 of the Effective Date Year)

Mbr #

Last Name

First Name

Middle

Initial

Relationship to Head

of Household

Date of Birth

(MM/DD/YYYY)

Student Status

(Check One)

Last 4 digits of

Social Security #

HEAD

PART III. GROSS ANNUAL INCOME (USE ANNUAL AMOUNTS)

Mbr #

(A)

Employment or Wages

(B)

Soc. Security/Pensions

(C)

Public Assistance

(D)

Other Income

TOTALS

Add totals from (A) through (D), above TOTAL INCOME (E):

PART IV. INCOME FROM ASSETS

Mbr #

(F)

Type of Asset

(G)

C/I

(H)

Cash Value of Asset

(I)

Annual Income from Asset

TOTALS:

Enter Column (H) Total

Passbook Rate

If over $5000

$_____________

X 0.06%

= (J) Imputed Income

Enter the greater of the total of column I, or J: imputed income TOTAL INCOME FROM ASSETS (K)

(L) Total Annual Household Income from all Sources [Add (E) + (K)]

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. I/we agree to notify the landlord immediately upon any member becoming a full time student.

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

FT/PT/NA

(Date)

Tenant Income Certification (April 2021)

PART V. DETERMINATION OF INCOME ELIGIBILITY

RECERTIFICATION ONLY:

TOTAL ANNUAL HOUSEHOLD

INCOME FROM ALL SOURCES:

From item (L) on page 1

Unit Meets Federal

Income Restriction at:

 60%  50%

Current Federal LIHTC

Income Limit x 140%:

If Applicable, Current Federal Bond

Income Limit per Family Size:

Household Income as of Move-in:

Or Federal A.I.T. at:

 80%  70%  60%  50%

 40%  30%  20%

Unit Meets State Deeper

Targeting Income Restriction

at:

 Other ______%

Household Income exceeds

140% at recertification:

 Yes  No

Household Size at Move-in:

PART VI. RENT

Tenant Paid Monthly Rent:

Federal Rent Assistance: $____________ *Source: ______

Monthly Utility Allowance:

Other Monthly Non-optional charges:

Non-Federal Rent Assistance: $____________ (*0-8)

Total Monthly Rent Assistance: $____________

GROSS MONTHLY RENT FOR UNIT:

(Tenant paid rent plus Utility Allowance &

other non-optional charges)

*Source of Federal Assistance

1 **HUD Multi-Family Project Based Rental Assistance (PBRA)

2 Section 8 Moderate Rehabilitation

3 Public Housing Operating Subsidy

4 HOME Rental Assistance

5 HUD Housing Choice Voucher (HCV), tenant-based

6 HUD Project-Based Voucher (PBV)

7 USDA Section 521 Rental Assistance Program

8 Other Federal Rental Assistance

0 Missing

** (PBRA) Includes: Section 8 New Construction/Substantial Rehabilitation;

Section 8 Loan Management; Section 8 Property Disposition; Section 202

Project Rental Assistance Contracts (PRAC)

Maximum Federal LIHTC Rent Limit for

this unit:

If Applicable, Maximum Federal & State

LIHTC Bond Rent Limit for this unit:

Unit Meets Federal Rent Restriction at:

Or Federal A.I.T. at:

If Applicable, Unit Meets Bond Rent

Restriction at:

Unit Meets State Deeper

Targeting Rent Restriction at:

 60%  50%

 80%  70%  60%

 50%  40%  30%

 20%

 60%  50%

 Other: ________%

PART VII. STUDENT STATUS

*Student Explanation:

ARE ALL OCCUPANTS FULL TIME STUDENTS? If yes, Enter student explanation*

1 AFDC / TANF Assistance

(also attach documentation)

2 Job Training Program

 Yes  No

3 Single Parent/Dependent Child

Enter

1-5

4 Married/Joint Return

5 Former Foster Care

PART VIII. PROGRAM TYPE

Identify the program(s) for which this household’s unit will be counted toward the property’s occupancy requirements.

Select one of the following.

 9% Allocated Federal Housing Tax Credit

 4% Allocated Federal Housing Tax Credit

 Tax-Exempt Bond Only (No tax credits)

Select all that apply.

 HOME (including TCAP)

 CDBG

 Other HUD, including 202, 811, and 236

 National Housing Trust Fund

 USDA Rural Housing Service, including 514, 515, and 538

 Other state or local housing programs

SIGNATURE OF OWNER/REPRESENTATIVE

Based on the representations herein and upon the proof 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 Section 42 of the Internal Revenue Code, as amended, and the Land Use Restriction

Agreement (if applicable), to live in a unit in this Project.

SIGNATURE OF OWNER/REPRESENTATIVE

DATE

Current Federal LIHTC Income Limit per

Family Size (Federal Income Restriction at

60%, 50% or A.I.T. (20% - 80%)):

Tenant Income Certification (April 2021)

PART IX. SUPPLEMENTAL INFORMATION FORM

The California Tax Credit Allocation Committee (CTCAC) requests the following information in order to comply with the Housing

and Economic Recovery Act (HERA) of 2008, which requires all Low Income Housing Tax Credit (LIHTC) properties to collect and

submit to the U.S. Department of Housing and Urban Development (HUD), certain demographic and economic information on tenants

residing in LIHTC financed properties. Although the CTCAC would appreciate receiving this information, you may choose not to

furnish it. You will not be discriminated against on the basis of this information, or on whether or not you choose to furnish it. If you

do not wish to furnish this information, please check the box at the bottom of the page and initial.

Enter both Ethnicity and Race codes for each household member (see below for codes).

TENANT DEMOGRAPHIC PROFILE

Mbr #

Last Name

First Name

Middle

Initial

Race

Ethnicity

Disabled

The Following Race Codes should be used:

1 – White – A person having origins in any of the original people of Europe, the Middle East or North Africa.

2 – Black/African American – A person having origins in any of the black racial groups of Africa. Terms such as “Haitian” apply to this

category.

3 – American Indian/Alaska Native – A person having origins in any of the original peoples of North and South America (including Central

America), and who maintain tribal affiliation or community attachment.

4 – Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent:

4a – Asian India 4e – Korean

4b – Chinese 4f – Vietnamese

4c – Filipino 4g – Other Asian

4d – Japanese

5 – Native Hawaiian/Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other

Pacific Islands:

5a – Native Hawaiian 5c – Samoan

5b – Guamanian or Chamorro 5d – Other Pacific Islander

6 – Other

7 – Did not respond. (Please initial below)

Note: Multiple racial categories may be indicated as such: 31 – American Indian/Alaska Native & White, 41 – Asian & White, etc.

The Following Ethnicity Codes should be used:

1 – Hispanic – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Terms such as “Latino” or “Spanish Origin” apply to this category.

2 – Not Hispanic – A person not of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless

of race.

3 – Did not respond. (Please initial below)

Disability Status:

1 – Yes

If any member of the household is disabled according to Fair Housing Act definition for handicap (disability):

• A physical or mental impairment which substantially limits one or more major life activities; a record of such an impairment or

being regarded as having such an impairment. For a definition of “physical or mental impairment” and other terms used, please see

24 CFR 100.201, available at http://fairhousing.com/legal-research/hud-regulations/24-cfr-100201-definitions.

• “Handicap” does not include current, illegal use of or addiction to a controlled substance.

• An individual shall not be considered to have a handicap solely because that individual is a transgender.

2 – No

3 – Did not respond (Please initial below)

 Resident/Applicant: I do not wish to furnish information regarding ethnicity, race and other household composition.

(Initials) __________ __________ _________ __________ __________ __________ __________

(HH#) 1. 2. 3. 4. 5. 6. 7.

Tenant Income Certification (April 2021)

INSTRUCTIONS FOR COMPLETING

TENANT INCOME CERTIFICATION

This form is to be completed by the owner or an authorized representative.

Part I - Development Data

Enter the type of tenant certification: Initial Certification (move-in), Recertification (annual recertification), or Other. If other, designate the purpose

of the recertification (i.e., a unit transfer, a change in household composition, or other state-required recertification).

Effective Date

Enter the effective date of the certification. For move-in, this should be the move-in date.

For annual income recertification’s, this effective date should be no later than one year

from the effective date of the previous (re)certification.

Move-In Date

Enter the most recent date the household tax credit qualified. This could be the move-in

date or in an acquisition rehab property, this is not the date the tenant moved into the

unit, it is the most recent date the management company income qualified the unit for

tax credit purposes.

Property Name

Enter the name of the development.

County

TCAC#

Enter the county (or equivalent) in which the building is located.

Enter the project number assigned to the property by TCAC. Please include hyphens

between the state abbreviation, four digit allocating year, and project specific number.

For example: CA-2010-123

BIN #

Enter the building number assigned to the building (from IRS Form 8609).

Address

Enter the physical address of the building, including street number and name, city, state,

and zip code.

If applicable, CDLAC#

If project is awarded 4% bonds please enter the project number assigned to the property

by CDLAC. Please include hyphens between the state abbreviation, four digit allocating

year, and project specific number. For example: 16-436

Unit Number

Enter the unit number.

# Bedrooms

Square Footage

Vacant Unit

Enter the number of bedrooms in the unit.

Enter the square footage for the entire unit.

Check if unit was vacant on December 31 of requesting year. For example, for the

collection of 2011 data, this would refer to December 31, 2011.

Part II - Household Composition

List all occupants of the unit. State each household member’s relationship to the head of household by using one of the following definitions:

Head of Household

Spouse

Unborn Child/Anticipated

Adult Co-Tenant

Other Family Member

Adoption or Foster

Child

Foster child(ren)/adult(s)

Live-in Caretaker

None of the above

Date of Birth

Student Status

Last Four Digits of Social Security

Number

Enter each household member’s date of birth.

Check FT for Full-time student, PT for Part-time student, or N/A if household member

is not a student and question does not apply.

For each tenant 15 years of age or older, enter the last four digits of the social security

number or the last four digits of the alien registration number. If the last four digits of

SSN or alien registration is missing, enter 0000. For tenants under age 15, social security

number not required, although please enter 0000.

If there are more than 7 occupants, use an additional sheet of paper to list the remaining household members and attach it to the certification.

Tenant Income Certification (April 2021)

Part III - Annual Income

See HUD Handbook 4350.3 for complete instructions on verifying and calculating income, including acceptable forms of verification.

From the third party verification forms obtained from each income source, enter the gross amount anticipated to be received for the twelve months

from the effective date of the (re)certification. Complete a separate line for each income-earning member. List each respective household member

number from Part II. Include anticipated income only if documentation exists verifying pending employment. If any adult states zero-income, please

note “zero” in the columns of Part III.

Column (A)

Enter the annual amount of wages, salaries, tips, commissions, bonuses, and other income from employment;

distributed profits and/or net income from a business.

Column (B)

Enter the annual amount of Social Security, Supplemental Security Income, pensions, military retirement, etc.

Column (C)

Enter the annual amount of income received from public assistance (i.e., TANF, general assistance, disability,

etc.).

Column (D)

Enter the annual amount of alimony, child support, unemployment benefits, or any other income regularly

received by the household.

Row (E)

Add the totals from columns (A) through (D), above. Enter this amount.

Part IV - Income from Assets

See HUD Handbook 4350.3 for complete instructions on verifying and calculating income from assets, including acceptable forms of

verification.

From the third party verification forms obtained from each asset source, list the gross amount anticipated to be received during the twelve months

from the effective date of the certification. If individual household member income is provided, list the respective household member number from

Part II and complete a separate line for each member.

Column (F)

List the type of asset (i.e., checking account, savings account, etc.)

Column (G)

Enter C (for current, if the family currently owns or holds the asset), or I (for imputed, if the family has disposed

of the asset for less than fair market value within two years of the effective date of (re)certification).

Column (H)

Enter the cash value of the respective asset.

Column (I)

Enter the anticipated annual income from the asset (i.e., savings account balance multiplied by the annual

interest rate).

TOTALS

Add the total of Column (H) and Column (I), respectively.

If the total in Column (H) is greater than $5,000, you must do an imputed calculation of asset income. Enter the Total Cash Value, multiply by

0.06% and enter the amount in (J), Imputed Income.

Row (K)

Row (L)

Enter the greater of the total in Column (I) or (J)

Total Annual Household Income From all Sources Add (E) and (K) and enter the total

HOUSEHOLD CERTIFICATION AND SIGNATURES

After all verifications of income and/or assets have been received and calculated, each household member age 18 or older must sign and date the

Tenant Income Certification. For move-in, it is recommended that the Tenant Income Certification be signed no earlier than 5 days prior to the

effective date of the certification.

Total Annual Household Income from all

Sources

Current Federal LIHTC Income Limit per

Unit Meets Federal Income Restriction at

60%, 50% or A.I.T (20% - 80%)

Current Bond Income Limit per Family

Size

Part V – Determination of Income Eligibility

Enter the number from item (L).

Enter the Current Move-in Income Limit for the household size – specifically, the max income

limit for the federal 60%, 50% or A.I.T (20% - 80%) set aside.

Enter the Current most restrictive Move-in Income Limit for the household size – specifically, the

max income limit incorporating both federal and in some instances more restrictive state standards

as reflected in the 50% or 60% set aside detailed in the Bond Regulatory Agreement.

Tenant Income Certification (April 2021)

For recertifications only. Enter the household income from the move-in certification.

Enter the number of household members from the move-in certification.

For recertifications only. Multiply the current LIHTC Maximum Move-in Income Limit by

140% and enter the total. 140% is based on the Federal Set-Aside of 20/50 or 40/60, or

A.I.T. (20% - 60% = 140% X 60%, 70% = 140% X 70% and 80% = 140% X 80%) as

elected by the owner for the property, not deeper targeting elections of 30%, 40%,

45%, 50%, etc. Below, indicate whether the household income exceeds that total. If the

Gross Annual Income at recertification is greater than 140% of the LIHTC Income Limit per

Family Size at Move-in date (above), then the available unit rule must be followed.

Check the appropriate box for the income restriction that the household meets according to

what is required by the federal set-aside(s) for the project.

If your agency requires an income restriction lower than the federal limit, enter the percent

required.

Part VI - Rent

Household Income at Move-in

Household Size at Move-in

Current Federal LIHTC Income Limit x

140%

Unit Meets Federal Income Restriction

at or Federal A.I.T. at

Unit Meets State Deeper Targeting

Income Restriction at

Tenant Paid Monthly Rent

Federal Rent Assistance

Non-Federal Rent Assistance

Total Monthly Rent Assistance

Source of Federal Rent Assistance

Monthly Utility Allowance

Other Monthly Non-Optional Charges

Gross Monthly Rent for Unit

Maximum LIHTC Rent Limit for this

unit

Maximum LIHTC Bond Rent Limit for

this unit

Unit Meets Federal Rent Restriction at

or Federal A.I.T. at

Unit Meets Bond Rent Restriction at

Unit Meets State Deeper Targeting Rent

Restriction at

Enter the amount the tenant pays toward rent (not including rent assistance payments such as

Section 8).

Enter the amount of rent assistance received from a federal program, if any.

Enter the amount of non-federal rent assistance received, if any.

Enter the amount of total rent assistance received, if any.

If federal rent assistance is received, indicate the single program source.

Enter the utility allowance. If the owner pays all utilities, enter zero.

Enter the amount of non-optional charges, such as mandatory garage rent, storage lockers,

charges for services provided by the development, etc.

Enter the total of Tenant Paid Rent plus Utility Allowance and other non-optional charges.

The total may NOT include amounts other than Tenant Paid Rent, Utility Allowances and

other non-optional charges. In accordance with the definition of Gross Rent in IRC

§42(g)(2)(B), it may not include any rent assistance amount.

Enter the maximum allowable gross rent for the unit. This amount must be the maximum

amount allowed by the Current Income Limit per Family Size – specifically, the max rent

limit for the federal 50%, 60% or A.I.T. (20% - 80%) set aside. This does not include state

deeper targeting levels.

Enter the maximum allowable gross rent for the unit. This amount must be the maximum

amount allowed by the Current Income Limit per Family Size – specifically, the max rent

incorporating both federal and in some instances more restrictive state standards as reflected

in the 50% or 60% set aside detailed in the Bond Regulatory Agreement.

Indicate the appropriate rent restriction that the unit meets according to what is required by

the federal set-aside(s) for the project.

Indicate the appropriate rent restriction that the unit meets according to what is required by

the federal and state law for the project.

If your agency requires a rent restriction lower than the federal limit, enter the percent

required.

Part VII - Student Status

If all household members are full time* students, check “yes”. Full-time status is determined by the school the student attends. If at least one

household member is not a full-time student, check “no.”

If “yes” is checked, the appropriate exemption must be listed in the box to the right. If none of the exemptions apply, the household is ineligible to

rent the unit.

Tenant Income Certification (April 2021)

Part VIII – Program Type

Select the program(s) for which this household’s unit will be counted toward the property’s occupancy requirements. One response from the first

column must be selected.

SIGNATURE OF OWNER/REPRESENTATIVE

It is the responsibility of the owner or the owner’s representative to sign and date this document immediately following execution by the resident(s).

The responsibility of documenting and determining eligibility (including completing and signing the Tenant Income Certification form) and ensuring

such documentation is kept in the tenant file is extremely important and should be conducted by someone well trained in tax credit compliance.

These instructions should not be considered a complete guide on tax credit compliance. The responsibility for compliance with federal program

regulations lies with the owner of the building(s) for which the credit is allowable.

PART IX. SUPPLEMENTAL INFORMATION

Complete this portion of the form at move-in and at recertification’s (only if household composition has changed from the previous

year’s certification).

Tenant Demographic Profile

Complete for each member of the household, including minors. Use codes listed on

supplemental form for Race, Ethnicity, and Disability Status.

Resident/Applicant Initials

All tenants who wish not to furnish supplemental information should initial this section.

Parent/Guardian may complete and initial for minor child(ren).