Income Eligible Worksheet

INCOME ELIGIBLE WORKSHEET

Clare Meadows offers income eligible senior apartments (age 55+) for those that qualify per the WHEDA (Wisconsin Housing & Economic Development Authority) Guidelines. Please Complete the below estimates to see if you think you would qualify for an income eligible apartment. Note that if you apply for an available income eligible apartment, all sources of income & assets will be verified by Clare Meadows. Verifications will be requested by Clare Meadows to each financial institution per WHEDA Guidelines.

Income Eligibility Requirements - Income must not exceed:

1 person household: $42,900

2 person household: $49,020

Date

YYYY

Name

First Name

Last Name

Name

First Name

Last Name

ESTIMATED GROSS INCOME (monthly)

Social Security

Disability or SSI

Pension(s)

Veteran Benefits

Employment

Unemployment

Alimony

IRA/Annuity Withdrawals

Dividends

Rent Paid to you

Other support or income

Total Monthly income

Annual Income (A)

(Monthly Income Multiplied by 12)

ASSETS (list the value of all assets)

Checking

Savings/Money Market

CD's

Mutual Funds

401K/IRA

Stocks

Bonds

Life Insurance (cash surrender value)

House/Real Estate (FMV)

$ gifted away past 24 mo's

Other

Total Assets

Total Assets Multiplied by .40% (B)

Total Estimated Annual Gross Income (per the WHEDA Guidelines) (A+B)

We encourage and support the nation's affirmative housing program in which there are no barriers to obtaining housing because of race, color, religion, sex, national origin, handicap, or familial status.