• Tools and Templates

HOME Sample Self-Certification of Annual Income Form

Date Published: June 2020



In an April 10, 2020 memorandum, HUD waived the HOME regulations at 24 CFR 92.203(a)(2) which requires Participating Jurisdictions (PJs) to determine annual household income by examining at least two months of source documentation. This sample self-certification of income form may be used by PJs to document annual income of (a) individuals and families that have lost employment or income either permanently or temporarily due to the COVID-19 pandemic and (b) homeless individuals and families who are applying for admission to a HOME rental unit or to participate in a HOME-funded emergency Tenant-Based Rental Assistance (TBRA) program.

The sample form is provided as a guide and should be adapted to include the PJ's policy and procedures regarding income eligibility requirements for emergency TBRA/rental assistance. The income sources listed on the form reflect annual income as defined by 24 CFR 5.609 (a)-(c) (Part 5) which is commonly used in HUD's rental and TBRA programs. PJs must update this form if they use the IRS 1040 adjusted gross income definition for its TBRA/rental programs.

The sample form is valid for use between April 10, 2020 and December 31, 2020, the HOME COVID-19 waiver period.

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