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5 <br /> Income Certification Form <br /> You may use this form to self-certify your household's gross monthly income. Please complete the <br /> table and certify that the information you provide is true and accurate to the best of your knowledge <br /> with your signature below. The person reviewing your application will use this information to <br /> calculate your household"s annual income and determine your eligibility for the program. <br /> Monthly Income Information <br /> Please list all income for the last full month for each household member. <br /> Household Household Household <br /> Member 1 Member 2 Member 3 <br /> (Homeowner) <br /> Full Name <br /> Wages, salaries,tips, commissions, etc. <br /> Unemployment Income <br /> Self-employment income <br /> Retirement/fixed income <br /> Other income <br /> Total income per month $ $ $ <br /> Household Household Household <br /> Member 4 Member 5 Member 6 <br /> Full Name <br /> Wages, salaries,tips, commissions, etc. <br /> Unemployment Income <br /> Self-employment income <br /> Retirement/fixed income <br /> Other income <br /> Total income per month $ $ $ <br /> I certify that to the best of my knowledge the monthly household income reported for each member of <br /> my household above is correct, complete and accurate as of the date this form is signed and completed. <br /> I agree to provide, upon request, documentation on all income sources to the Orange County <br /> Department of Housing and Community Development. <br /> Homeowner's Signature Date <br /> 3 <br />