Public Housing Form 5 of 6 - Under $5,000 Asset Certification - Roanoke-Chowan Regional Housing Authority

Public Housing Form 5 of 6 - Under $5,000 Asset Certification

RCRHNC Logo.

Roanoke Chowan Regional Housing Authority
8:30 AM - 5:00 PM Monday - Thursday
8:00 AM - 11:30 AM Friday
Except Holidays
205 Tinsley Way, Gaston, NC 27832
252.537.1051

Fields marked with * must be completed or form will not submit.

For households whose combined NET assets DO NOT exceed $5,000.00. Complete one form per household. Include assets from children of the household.*

I Understand

Household Name*

Household Address*

1. My/Our Household assets Include:

(A) Cash Value* - Savings Account

(B) Interest Rate* - Savings Account

(A x B) Annual Income - Savings Account

(A) Cash Value* - Checking Account

(B) Interest Rate* - Checking Account

(A x B) Annual Income - Checking Account

(A) Cash Value* - Cash on Hand

(B) Interest Rate* - Cash on Hand

(A x B) Annual Income - Cash on Hand

(A) Cash Value* - Safety Deposit Box

(B) Interest Rate* - Safety Deposit Box

(A x B) Annual Income - Safety Deposit Box

(A) Cash Value* - Cert of Deposit

(B) Interest Rate* - Cert of Deposit

(A x B) Annual Income - Cert of Deposit

(A) Cash Value* - Money Market Funds

(B) Interest Rate* - Money Market Funds

(A x B) Annual Income - Money Market Funds

(A) Cash Value* - Stocks

(B) Interest Rate* - Stocks

(A x B) Annual Income - Stocks

(A) Cash Value* - Bonds

(B) Interest Rate* - Bonds

(A x B) Annual Income - Bonds

(A) Cash Value* - IRA Accounts

(B) Interest Rate* - IRA Accounts

(A x B) Annual Income - IRA Accounts

(A) Cash Value* - 401k Accounts

(B) Interest Rate* - 401k Accounts

(A x B) Annual Income - 401k Accounts

(A) Cash Value* - Keogh Accounts

(B) Interest Rate* - Keogh Accounts

(A x B) Annual Income - Keogh Accounts

(A) Cash Value* - Trust Funds

(B) Interest Rate* - Trust Funds

(A x B) Annual Income - Trust Funds

(A) Cash Value* - Equity in Real Estate

(B) Interest Rate* - Equity in Real Estate

(A x B) Annual Income - Equity in Real Estate

(A) Cash Value* - Land Contracts

(B) Interest Rate* - Land Contracts

(A x B) Annual Income - Land Contracts

(A) Cash Value* - Lump Sum Receipts

(B) Interest Rate* - Lump Sum Receipts

(A x B) Annual Income - Lump Sum Receipts

(A) Cash Value* - Capital Investments

(B) Interest Rate* - Capital Investments

(A x B) Annual Income - Capital Investments

(A) Cash Value* - Life Ins Policies (Whole Only)

(B) Interest Rate* - Life Ins Policies (Whole Only)

(A x B) Annual Income - Life Ins Policies (Whole Only)

(A) Cash Value* - Other Retirement / Pension

(B) Interest Rate* - Other Retirement / Pension

(A x B) Annual Income - Other Retirement / Pension

(A) Cash Value* - Personal Property

(B) Interest Rate* - Personal Property

(A x B) Annual Income - Personal Property

(A) Cash Value* - Other (List)

(B) Interest Rate* - Other (List)

(A x B) Annual Income - Other (List)

Other (List)

PLEASE NOTE: Certain Funds (e.g. Retirement, Pension, Trust) may or may not be (fully) accessible to you. Include only those amounts which are:

* Cash Value Is defined as market value minus the cost of converting the asset to cash, such as broker's fees, settlement costs, outstanding loans, early withdrawal penalties, etc.

** Personal property held as an Investment may Include, but Is not limited to, gem or coin collections, art, antique cars, etc. DO NOT Include necessary personal property such as, but not limited to, household furniture, dally use of autos, clothing, assets of an active business, or special equipment for use of disabled.

2. Within the past two (2) years, I/We have sold or given away assets (Including case, real estate, etc.) for more than $1000.00 below fair market value (FMV). Those amounts* are Included above and are equal to a total of $________ the difference between FMV and the amount received, for each asset on which this occurred.*

Yes

If yes, total:

3. I/We have NOT sold or given away any assets (Including cash, real estate, etc.) for more than $1000.00 below Fair Market Value (FMV) durlng the past two (2) years.
*

Yes

4. I/We DO NOT have any assets at this time.*

Yes

The Net Family Assets (as defined In CFR 813.102) above do not exceed $5000.00 AND the Annual Income from the Net Family Assets Is (This amount Is Included In the total Gross Annual Income.)

Under penalty of perjury, I/We certify that the information presented In this certification Is true and accurate to the best of my/our knowledge. The undersigned further understand(s) that providing false Information herein constitutes an act of fraud. False, misleading or Incomplete Information may result In the termination of a Lease Agreement.

Applicant/Resident Signature 1*

Applicant/Resident Signature 2

Applicant/Resident Signature 3

Applicant/Resident Signature 4

Date *

Used Pursuant to Notice PIH 2013·03(HA) which Expires March 31, 2014.