Instructions: The Housing Agency may complete this form and retain it in the tenant file. This specific form is optional; however evidence of the computation is required. 

Contact Information	
Applicant Name:      	
Proposed Rental Address:      	
Admission Date:      	Bedroom Size:      	Contract Rent:      	
Owner Name:      	Owner Phone:      	
Owner Address:      	
Bridges Contract Effective Date:      	Income Certification Effective Date:      	
Rent Payment Effective Date:      	Recertification Due Date:      	

Income Information
List all household income, including income from employment, benefits, and assets such as savings and checking accounts. See Program Guide for details. Attach additional sheets if necessary. 

Family Member	Source	Annual Income	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
			Total 	     	

Calculation	
1.	Total Household Annual Income (from table above)	$      	
2.	Gross Monthly Income (Line 1 divided by 12)	$      	
3.	30% of Monthly Income (Line 2 x .3) Minimum tenant portion of rent	$      	
4.	40% of Monthly Income (Line 2 x .4) Maximum tenant portion of rent	$      	
5.	Monthly Rent Due to Owner (Contract Rent)	$      	
6. 	Local Payment Standard (LPS) or Fair Market Rent (FMR)	$      	
7.	Participant Rent (Line 3, up to amount in Line 4). If the total rent to owner exceeds the LPS or FMR, tenant can pay a maximum of 40% of income toward rent.	
$      	
8.	Subsidy Rent (Line 5 minus Line 7)		$      	

I certify that the information on this form has been verified, that the family was eligible at admission, and the family has certified that they have given accurate and complete information.

	       	
Signature of Housing Agency Representative                                                     	Date