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Initial Certification ____
Annual Recertification ____
(Check One)
EXHIBIT "A"
CERTIFICATION OF TENANT ELIGIBILITY
RE: Stuart Gardens Housing Partners, LP
City of Newport News, Virginia
I/We, the undersigned, being first duly sworn, state that I/we have read and answered fully, and
truthfully each of the following questions for all persons who are to occupy the unit in the above apartment
project for which application is made, all of whom are listed below:
1. 2. 3. 4. 5.
Name of Relationship to
Members Head of Social Place of
of the Household Household Age Security Number Employment
6. The anticipated income of all the above persons during the 12-month period beginning this
date,
(a) including all wages and salaries, over-time pay, commissions, fees, tips and bonuses before
payroll deductions; net income from the operation of a business or profession or from the rental of real or
personal property (without deducting expenditures for business expansion or amortization of capital
indebtedness or the allowance for depreciation of capital assets); interest and dividends; the full amount of
periodic payments received from social security, annuities, insurance policies, retirement funds, pensions,
disability or death benefits and other similar types of periodic receipts; payments in lieu of earnings, such
as unemployment and disability compensation, workers' compensation and severance pay; the maximum
amount of public assistance available to the above persons; periodic and determinable allowances, such as
alimony and child support payments and regular contributions and gifts received from persons not residing
in the dwelling; all regular pay, special pay and allowances of a member of the Armed Forces (whether or
not living in the dwelling) who is the head of the household or spouse or other person whose dependents
are residing in the unit; and any earned income tax credit to the extent that it exceeds income tax liability,
but
(b) excluding casual, sporadic or irregular gifts; amounts which are specifically for or in
reimbursement of medical expense; lump sum additions to family assets, such as inheritances, insurance
payments (including payments under health and accident insurance and worker's compensation), capital
gains and settlement for personal or property losses; amounts of educational scholarships paid directly to
the student or the educational institution, and amounts paid by the government to a veteran for use in
meeting the costs of tuition, fees, books and equipment, but in either case only to the extent used for such
purposes; special pay to a serviceman head of a family who is away from home and exposed to hostile fire;
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