Financial- Cromwell, Samuel (Previous Tenant)

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~ ~ Oregon Department of Transporfation RELOCATION INCOME VERIFICATION Page _ of _ Page(s) Each member of the household over 18 vears of aae must complete this form. Name: Social Security Number: - J G- y9~ Occupation: .~ ~ ~ Tel pho e: ~ ~~ Employer Name: Employer Telephone: ~~ ~ Employe Address: /i G ~ ~~ . CONFIDENTIAL INFORMATION HOUSEHOLDINCOME LAST 12 ~~10NTHS HOUSEHOLD ASSETS Gross Wages, Commissions, Bonuses, Tips, and Military Pay $ Net Business Income $ Retirement Benefits $ Unemployment $ Disability Payments $ Alimony/ Child Support $ Other. $ $ Line A ....................Total $ File No. I Name Section Highway County FAP No. Equity-Other Real Estate $ Savings Accounts $ Stocks and Bonds $ Loans/ Accts Receivable $ Other Captial $ Investments or Assets $ ~ $ $ $ Line B...........Total $ INCOME ON ASSETS Interest & Dividends Net Income From Rentals (Real & Personal) Other: Line C .....................Total $ ~ $ $ $ COMPUTATION: Enter the amount from Line A .................................... $ If Line B is over $5,000, enter 10% of Line B. $ If Line B is not over $5,000, enter zero. If Line B is under $5,000, enter amount from Line C $ Total $ Divided by 12 $ If page 1, enter the totals from the other pages $ Total of all pages $ I certify that the information stated above is correct. I understand that inquiries may be made to verify this information. The sole purpose of this form is the determination of eligibility for relocation assistance and replacement housing benefits in accordance with Oregon Department of Transportation regulations. Relocation Agent Dale Applicant Date Form 102 (1/14/95) RELOCATION