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Fuel and Electric Assistance Program Rental Income Declaration

Net Profit Divided by # of units Cost per Unit Cost of your Unit Total Expenses Minus Adjusted Expenses Gross Income Minus Adjusted Expenses Total Expenses Applicants who collect rental income are required to provide all documentation for the prior 365 days of income. Generally, this can be provided with a complete copy of the current year tax return with all schedules included. If you collect rental income but do not file taxes, you are required to submit this completed rental income declaration along with documentation of income and expenses. Please note: • You must complete all information and sign and date the bottom of the form. • Along with form, you must present supporting documentation in an orderly fashion. Documents should be organized in date order and, if including deductions, should be clearly labelled.

Applicant Name ____________________________________________________________________ Rental Type ☐ Apartment ☐ Condo ☐ Duplex ☐ Mobile Home ☐ Single Family ☐ Room Rental Address _________________________________ City _______________ Zip Code ________ 365 Day Period From____________ To ____________ Complete the below for this time period.

Gross Income from Rental Property $_____________________________________ Expenses – List the totals for any rental-related expense for the period indicated above that you would like to see deducted. You must provide documentation (receipts) as proof of expenses in order to have expenses deducted. 1. Heating and Electrical Costs $_____________ If these costs are included in the rent only

2. Property Insurance

$_____________

3. Property Taxes

$_____________

4. Repairs (under $1,000) $_____________

5. Repairs (major - $1,000+) $_____________ List repair __________________________ 6. Services (cleaning, legal) $_____________ 7. Other Expenses

$_____________ List expense(s) ______________________ Total Expenses (lines 1 through 7) = $______________ If you live in one of the units in this building, please complete the following: $________________

________________ = $________________ $________________ ________________ = $________________

$________________

________________ = $_______________ I certify that the above information is complete, accurate, and true to the best of my knowledge. I will provide the necessary documentation for the above information upon request if necessary. If understand that if I have intentionally falsified any of this information, I could be fined and/or imprisoned. ________________________________________ ____________________________________________ Signature

Date

If you do NOT live on the property:

Gross Income minus Total Expenses = Net Profit