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~.- , `'~;,' <br />~Oregon Deparfinent of Transportation RELOCATION <br />INCOME VERIFICATION <br />Page _ of _ Page(s) <br />Each member of the household over 18 vears of aqe must complete this form. <br />Nam : <br />.- Social Security Number: <br />~ <br />G~ '(~ - <br />Occupation: Telephone: <br />~` <br />Emplpyer Na e: Employer Telephone: <br />U 1 ` z~ ~-- z L <br />Employer Address: <br />CONFIDENTIAL INFORMATION <br />HOUSEHOLDINCOME <br />LAST i2 PJIONTHS HOUSEHOLD ASSETS <br />Gross Wages, <br />File No. <br />Name <br />Section <br />Highway <br />County <br />FAP Na <br />Commissions, Bonuses, Equity-Other Real Estate $ <br />Tips, and Military Pay $ Savings Accounts $ <br />Net Business Income $ Stocks and Bonds $ <br />Retirement Benefits $ Loans/ Accts Receivable $ <br />Unemployment $ Other Captiai $ <br />Disability Payments $ Investments or Assets $ <br />Alimony/ Child Support $ ~ $ <br />Other: $ ~ $ <br />$ $ <br />Line A ....................Total $ Line B...........Total $ <br />INCOME ON ASSETS <br />Interest & Dividends $ <br />Net Income From Rentals g <br />(Real & Personal) <br />Other: $ <br />$ <br />Line C .....................Total $ <br />COMPUTATION: <br />Enter the amount from Line A .................................... $ <br />If Line B is over $5,000, enter 10% of Line B. $ <br />If Line B is not over $5,000, enter zero. <br />If Line B is under $5,000, enter amount from Line C $ <br />Total $ <br />Divided by 12 $ <br />If page 1, enter <br />the totals from <br />the other pages $ <br />Total of all <br />, ~ pages $ <br />I certify that the information stated above is correct. I understand that inquiries may be made to verify this <br />information. The sole purpose of this form is the determination of eligibility for rel ocation assistance and <br />replacement housing benefits in accordance with Oregon Depa~tment of Transportation regulations. <br />Relocation Agent Date Applicant Oate <br />Form 102 (1/14/95) <br />RELOCATION <br />