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relocation payments under Title II of the Uniform Relocation Assistance and Real Property Acquisition
Policies Act of 1970; foster child care payments; the value of coupon allotments for the purchase of food
pursuant to the Food Stamp Act of 1964 which is in excess of the amount actually charged for the
allotments; and payments received pursuant to participation in ACTION volunteer programs.
And the total for each member is as follows:
Name Amount
_________________________________________ ______________________
_________________________________________ ______________________
_________________________________________ ______________________
7. If any of the persons described above (or whose income or contributions was included in
item 6) has any savings, stocks, bonds, equity in real property or other form of capital investment, provide:
(a) the total value of all such assets owned by all such persons: $_____________,
(b) the amount of income expected to be derived from such assets in the 12-month period
commencing this date: $________________ and
(c) the amount of such income which is included in item 6: $______________.
8. (a) Will all of the persons listed in column 1 above be or have they been full-time
students during five calendar months of this calendar year at an educational institution (other than a
correspondence school) with regular faculty and students?
Yes _________________ No ____________________
(b) Is any such person (other than nonresident aliens) married and eligible to file a joint federal
income tax return?
Yes _________________ No ____________________
We acknowledge that all of the above information is relevant to the status under federal income tax
law of the interest on bonds issued to finance construction of the Project for which application is being
made. We consent to the disclosure of such information to the issuer of such bonds, the holders of such
bonds, any trustee acting on their behalf and any authorized agent of the Treasury Department or the Internal
Revenue Service.
Head of Household
Other Spouse
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