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

Contact Information	
Applicant/Participant Name:      	
Rental Unit Address:      	
Admission Date:      	Bedroom Size:       Voucher Size     	Contract Rent:      	
Owner Name:      	Owner Phone:      	
Owner Address:      	
     	Certification Effective Date:      	
Rent Payment Effective Date (Is this field the same as Certification Effective Date?):      	Next Annual Certification Due Date:      	

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

Family Member	Source	Annual Income	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
			Total Household Annual Income 	                       8400   	
Calculation                                                                                                                                                                                   Example:	
1.	Total Household Annual Income (from Income Information section above)	$                         8400             	
2.	Gross Monthly Income (Line 1 divided by 12)	$                         700	
3.	30% of Monthly Income (Line 2 x .3) Minimum tenant portion of rent	$                         210	
4.	40% of Monthly Income (Line 2 x .4) Maximum tenant portion of rent	$                         280	
5.	Monthly Rent Due to Owner (Contract Rent)	$                         1585	
6.	Utility Allowance	$                         246     	
7.	Gross Rent (Line 5 plus Line 6)	$                         1831     	
8. 	Local Payment Standard (LPS) or Fair Market Rent (FMR) (whichever is greater)
For Shared Housing: the lower of the LPS/FMR for the family voucher size or the prorata share of the LPS/FMR for the shared housing unit size. See example below.	$                         1800       	
9.	Lesser of Line 7 or Line 8	$                          1800	
10.	Minimum tenant portion of rent (Line 3)	$                          210	
11.	Total Subsidy (Line 9 minus Line 10)	$                          1590	
12.	Family Share (Line 7 minus Line 11) NOTE: Cannot exceed Line 4	$                          241	
13.	Rental Assistance Payment to Owner (lesser of Line 5 or Line 11)	$                          1585	
14.	Utility Reimbursement Payment to Applicant/Participant (Line 11 minus Line 13)	$                          5                 	

Shared Housing Prorata LPS/FMR and Utility Allowance Calculation	
A. Local Payment Standard (LPS) or Fair Market Rent (FMR) for the family unit size listed on the Voucher	$                              1800	
B. Number of bedrooms in shared housing	#                               4	
C. Number of bedrooms occupied by household	#                               3	
D. Prorata share (divide the number of bedrooms in shared housing by the number of bedrooms occupied by the household, Line B divided by Line C)	#                              .75	
E. LPS/FMR for number of bedrooms in shared housing	$                              2000	
F. Pro rata LPS/FMR (Line E multiplied by Line D)	$                              1500	
H. Shared Housing Pro rata LPS/FMR to use in Line 8 above (Lesser of Line A or Line F)	$                              1500	
I. Utility allowance for the family unit size listed on the voucher	$                              100	
J. Utility allowance for the number of bedrooms in shared housing	$                              200	
K. Prorata share of utility allowance (Line J multiplied by Line D)	$                              150	
8. Shared housing pro rata utility allowance to use in Line 6 above (Lesser of Line I or Line K) 
Example: A family holds a 2-bedroom voucher. The family decides to occupy 3 out of 4 bedrooms available in the unit.
The utility allowance for a 4-bedroom unit equals $200
The utility allowance for a 2-bedroom unit equals $100
The prorata share of the utility allowance is $150 (3/4 of $200)
The HRA will use the 2-bedroom utility allowance of $100.	$                              150	

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 been given accurate and complete information.
	       	
Signature of Housing Agency Representative                                                     	Date