"Self-certification of Annual Income to Implement Covid-19 Regulatory Waiver - Home Investment Partnerships Program - Sample" - New York

Self-certification of Annual Income to Implement Covid-19 Regulatory Waiver - Home Investment Partnerships Program - Sample is a legal document that was released by the New York State Homes and Community Renewal - a government authority operating within New York.

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HOME INVESTMENT PARTNERSHIPS PROGRAM
SAMPLE SELF-CERTIFICATION OF ANNUAL INCOME FORM
PURPOSE:
On December 4, 2020, HUD revised and extended the applicability of several statutory
suspensions and regulatory waivers included in the April 10, 2020, memoranda,
Availability of
Waivers and Suspensions of the HOME Program Requirements in Response to COVID-19
Pandemic
and
Suspensions and Waivers to Facilitate Use of HOME-Assisted Tenant-Based Rental
Assistance (TBRA) for Emergency and Short-term Assistance in Response to COVID-19 Pandemic
(the “April 2020 memos”).
In the April 2020 memos, HUD waived the HOME regulations at 24 CFR 92.203(a)(2) which
requires Participating Jurisdictions (PJs) to determine annual household income by examining at
least two months of source documentation. The waiver permits PJs to follow the regulations at
24 CFR 92.203(a)(1)(ii) and obtain a written statement of the amount of the family’s anticipated
annual income and household size, along with a certification that the information is complete
and accurate in lieu of requiring a review of source documentation. In the revised memos, HUD
extended the waiver period through September 30, 2021, permits PJs to use self-certification of
income during annual re-examinations of rental units, including income determinations that fall
on the sixth year of the affordability period. In addition, HUD provided two additional income
exclusions, a) Federal Pandemic Unemployment Compensation - $600 per week and (b) Lost
Wages Supplemental Payment Assistance- up to $400 per week. If a PJ chooses to use this
waiver, the PJ must ensure that self-certified income takes into consideration all income.
APPLICABILITY:
This sample self-certification of income form may be used by PJs to document annual income of
New applicants of HOME-assisted rental units,
New applicants of HOME TBRA programs including emergency and short-term TBRA,
Existing TBRA tenants requiring assistance under an emergency TBRA program,
Existing tenants of HOME rental units up for income re-examination (annual and 6
year
th
redeterminations), and
Prior applicants denied assistance due to the inclusion of excludable unemployment
benefits.
This form must accompany the application for assistance and be kept as a record in the
tenant/project file.
TIMEFRAME:
The sample form supersedes previous version and is valid for use through September 30, 2021,
the extended HOME COVID-19 waiver period.
DISCLOSURE:
The sample form is provided as a guide and should be adapted to include the PJ’s policy and
procedures regarding income eligibility requirements for its HOME rental program and TBRA
programs (non-emergency and emergency/short term). Depending upon the PJ’s application
intake process, this form may be filled out between the PJ and the applicant, or by the applicant.
Applicants can complete the form using current income and asset information available to them;
however, if information is unknown, applicants may obtain it from the financial institution that
holds the asset. The PJ should ensure the instructions are clear in each section when they adapt
the form for its program. In addition, the form may be adapted if the PJ will base the amount of
emergency TBRA on the adjusted income of the family in accordance with 24 CFR 5.611. The
income sources listed on the form reflect annual income as defined by 24 CFR 5.609 (a)-(c) (Part
5) which is commonly used in HUD’s rental and TBRA programs. PJs must update this form if
they use the IRS 1040 adjusted gross income definition for its TBRA/rental programs.
Version December 4, 2020
HOME INVESTMENT PARTNERSHIPS PROGRAM
SAMPLE SELF-CERTIFICATION OF ANNUAL INCOME FORM
PURPOSE:
On December 4, 2020, HUD revised and extended the applicability of several statutory
suspensions and regulatory waivers included in the April 10, 2020, memoranda,
Availability of
Waivers and Suspensions of the HOME Program Requirements in Response to COVID-19
Pandemic
and
Suspensions and Waivers to Facilitate Use of HOME-Assisted Tenant-Based Rental
Assistance (TBRA) for Emergency and Short-term Assistance in Response to COVID-19 Pandemic
(the “April 2020 memos”).
In the April 2020 memos, HUD waived the HOME regulations at 24 CFR 92.203(a)(2) which
requires Participating Jurisdictions (PJs) to determine annual household income by examining at
least two months of source documentation. The waiver permits PJs to follow the regulations at
24 CFR 92.203(a)(1)(ii) and obtain a written statement of the amount of the family’s anticipated
annual income and household size, along with a certification that the information is complete
and accurate in lieu of requiring a review of source documentation. In the revised memos, HUD
extended the waiver period through September 30, 2021, permits PJs to use self-certification of
income during annual re-examinations of rental units, including income determinations that fall
on the sixth year of the affordability period. In addition, HUD provided two additional income
exclusions, a) Federal Pandemic Unemployment Compensation - $600 per week and (b) Lost
Wages Supplemental Payment Assistance- up to $400 per week. If a PJ chooses to use this
waiver, the PJ must ensure that self-certified income takes into consideration all income.
APPLICABILITY:
This sample self-certification of income form may be used by PJs to document annual income of
New applicants of HOME-assisted rental units,
New applicants of HOME TBRA programs including emergency and short-term TBRA,
Existing TBRA tenants requiring assistance under an emergency TBRA program,
Existing tenants of HOME rental units up for income re-examination (annual and 6
year
th
redeterminations), and
Prior applicants denied assistance due to the inclusion of excludable unemployment
benefits.
This form must accompany the application for assistance and be kept as a record in the
tenant/project file.
TIMEFRAME:
The sample form supersedes previous version and is valid for use through September 30, 2021,
the extended HOME COVID-19 waiver period.
DISCLOSURE:
The sample form is provided as a guide and should be adapted to include the PJ’s policy and
procedures regarding income eligibility requirements for its HOME rental program and TBRA
programs (non-emergency and emergency/short term). Depending upon the PJ’s application
intake process, this form may be filled out between the PJ and the applicant, or by the applicant.
Applicants can complete the form using current income and asset information available to them;
however, if information is unknown, applicants may obtain it from the financial institution that
holds the asset. The PJ should ensure the instructions are clear in each section when they adapt
the form for its program. In addition, the form may be adapted if the PJ will base the amount of
emergency TBRA on the adjusted income of the family in accordance with 24 CFR 5.611. The
income sources listed on the form reflect annual income as defined by 24 CFR 5.609 (a)-(c) (Part
5) which is commonly used in HUD’s rental and TBRA programs. PJs must update this form if
they use the IRS 1040 adjusted gross income definition for its TBRA/rental programs.
Version December 4, 2020
HOME Investment Partnerships Program
Self-Certification of Annual Income to Implement COVID-19 Regulatory Waiver
INSTRUCTIONS:
Please complete one form and include the requested information for all persons in the household. Complete an
additional form if the applicant needs more space. The adult head of household must sign and date the form. This form
supersedes previous version and is valid for use through September 30, 2021.
PART I: ELIGIBILITY
HOME funded rental assistance is limited to income eligible families whose annual income does not exceed [XX] percent
of the area median income,
as determined by
HUD. In addition, emergency, or short term TBRA is limited to (a)
applicants who have lost employment or income either permanently or temporarily due to the COVID-19 pandemic and
to (b) homeless individuals or families.
***INSERT APPLICABLE HOME INCOME LIMITS***
For Emergency TBRA Programs Only: To comply with HOME program guidelines, the applicant must indicate which
eligibility category applies to their household. Do not complete the rest of this form if the household does not meet the
program’s income limits and one of the categories below.
Check all that apply:
Homeless
Experiencing financial hardship
If the applicant has experienced financial hardship as a result of the COVID-19 pandemic, the applicant must describe
how the household’s financial situation has changed (e.g., lost employment or reduced income either temporarily or
permanently).
PART II: HOUSEHOLD INFORMATION
Enter legal address (where the applicant currently lives) and contact information below. If household is experiencing
homelessness or is in temporary housing, provide a mailing address (where the applicant currently receives mail).
Legal Address
Mailing Address (if different from legal)
Street, Apt./Unit #
State, City, Zip Code
Phone Number(s)
Email(s)
Version 2, updated December 4, 2020
Page 1
HOME Investment Partnerships Program
Self-Certification of Annual Income to Implement COVID-19 Regulatory Waiver
Enter all household information below and indicate if any member is or will be a part-time/full-time student in the next
12 months. Do not include live-in-aides, children of live-in-aides, foster children, or foster adults.
Relationship to the
*Student
Birth Date
Household
Name
Head of Household
(Part/Full-
**Disabled
(mm/dd/
Member #
(Last, First, MI)
(co-head, spouse,
time,
(Y/N)
yyyy)
child, etc.)
Neither)
1
Head of Household
2
3
4
5
6
*Note for Applicant: Students do not qualify for HOME assistance unless the individual meets one of the exemptions
below. Check all that apply:
Over age 24
Veteran of the US Military
Married
Has dependent child/ren
Member is part of a household that is low-income
**Note for Administrator: the “Disabled” column is not required and only provided if deductions under adjusted
income at 24 CFR 5.611 will be applied for tenant-based rental assistance programs.
PART III: ANNUAL INCOME
Report all current income and income expected to be received in the next 12 months including long-term
unemployment compensation and all hazard pay. DO NOT INCLUDE: IRS Economic Impact Payments (stimulus checks),
Federal Pandemic Unemployment Compensation (the additional $600 per week), Lost Wages Supplemental Payment
Assistance (up to $400 per week), income of a live-in-aide, children of live-in-aides, foster children, foster adults, or the
income of minors.
Version 2, updated December 4, 2020
Page 2
HOME Investment Partnerships Program
Self-Certification of Annual Income to Implement COVID-19 Regulatory Waiver
Section A: For each household member (HH Mbr#) below, anticipate annual income for the next 12 months by
converting current income to annual figures. Convert wages/income by multiplying it by the frequency in which it is
received and factor in amounts that will terminate before the end of the next 12 months. Multiply weekly income by 52;
Bi-weekly income (received every other week) by 26; Semi-monthly income (received twice each month) by 24; and
Monthly income by 12. A full-time student, 18 years or older (excluding the head of household or spouse) should
exclude earnings in excess of $480 for annual income. Leave blank those that do not apply. To determine the total
income for the household, add up all columns on the last row of this chart.
HH Mbr#
HH Mbr#
HH Mbr#
HH Mbr#
HH Mbr#
HH Mbr#
Income Sources
1
2
3
4
5
6
Unemployment Compensation
(include regular unemployment, Pandemic
Unemployment Assistance and Pandemic Emergency
Unemployment Compensation)
$
$
$
$
$
$
(exclude Federal Pandemic Unemployment
Compensation; Lost Wages Supplement Payment
Assistance)
Wages, salary, overtime, hazard pay, commissions, fees,
$
$
$
$
$
$
tips, bonuses (before payroll deductions)
Net income from business and self-employment
(include income from independent contractors, Gig
$
$
$
$
$
$
economy jobs such as Etsy, Amazon, eBay, Uber, Lyft,
Instacart, Grubhub, etc.)
Interest, dividends, and other net income of any kind
$
$
$
$
$
$
from real or personal property (include rental income)
Social Security
(include disability/Supplemental; include gross amount
$
$
$
$
$
$
prior to any Medicare premiums)
Retirement/Pension/Insurance policy/Annuities
$
$
$
$
$
$
Disability or Death Benefits
$
$
$
$
$
$
(disability compensation)
Worker’s Compensation and Severance pay
$
$
$
$
$
$
Welfare Assistance Payments
$
$
$
$
$
$
(Temporary Assistance to Needy Families)
Regular Pay, special pay, and housing allowance for the
Armed Forces
$
$
$
$
$
$
(exclude military hazard pay)
Veterans Administration (VA) Benefits
$
$
$
$
$
$
(exclude deferred disability benefits)
Adoption Assistance Payments
$
$
$
$
$
$
(exclude amount in excess of $480)
Alimony or Child Support
$
$
$
$
$
$
(include only amounts expected)
Re-occurring cash gifts from private/nonprofit/charity
$
$
$
$
$
$
or friends/family who will not reside in the unit
Other (please describe):
$
$
$
$
$
$
_______________________________
Total for each HH Member
$
$
$
$
$
$
Section A: Total Income for Household
$
Version 2, updated December 4, 2020
Page 3
HOME Investment Partnerships Program
Self-Certification of Annual Income to Implement COVID-19 Regulatory Waiver
Section B - Income From Assets: Annual income includes income derived from assets to which household members have
access. Interest or dividends earned are counted as income even when the earnings are reinvested. Using the categories
below, report the (a) type of asset(s) held by each member of the household, (b) cash value of asset(s), and (c) the
income derived from the assets (report annual figures only). If the asset does not generate income, report zero. If the
household member does not have assets, leave blank. Calculate the totals on the last row of this chart.
Household
Assets Categories:
Member #
Checking, Savings, Mutual funds, Money Market Acct. Equity in
Rental Property, Retirement and Pensions, 401(K), Stocks, Bonds,
Treasury Bills, Certificate of Deposit, Annuities, Revocable Trust,
Interest/Dividends Earned
Cash Value of Asset
Mortgages or Deed of Trust, Whole Life Insurance policy, Lump
on the Assets
sum- inheritance, Lottery Winnings, Insurance Settlements,
Personal property held as an investment (e.g., antiques, gems, etc.)
1
$
$
2
$
$
3
$
$
4
$
$
5
$
$
6
$
$
Disposed Assets:
Household
Cash Value of Disposed
Income from Disposed
Assets given away for less than the fair market value in the last 24
Member #
Asset
Asset
months with value greater than $1,000, (e.g. sale of a home)
$
$
$
$
$
$
Box (B1)
Box (B2)
Total Value of Assets
Total Income from Assets
$
$
***To be completed by Program Administrator***
Box (B3)
If the amount in Box (B1) is greater than $5000,
Value of Imputed Asset
calculate the imputed value of the assets by multiplying
$
Box (B1) by the Passbook Savings rate of (.06%)
$
Section B: Total Income from Assets
(greater of box (B2) or (B3)
$
Total Household Annual Income (Sections A + B)
Version 2, updated December 4, 2020
Page 4
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