• Tools and Templates

Updated HOME Sample Self-Certification of Annual Income Form

Date Published: February 2021



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. On December 4, 2020, HUD issued an updated memorandum that extended the waiver period through September 30, 2021.

PJs can use the sample self-certification of income form to document the annual income of:

  • New applicants of HOME-assisted rental units
  • New applicants of HOME Tenant-Based Rental Assistance (TBRA) programs, including emergency and short-term TBRA
  • Existing TBRA tenants requiring assistance under an emergency TBRA program
  • Existing tenants of HOME rental units up for income re-examination (annual and 6th year redeterminations)
  • Prior applicants denied assistance due to the inclusion of excludable unemployment benefits

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.

Note: The original sample form was valid for use between April 10, 2020 and December 31, 2020, the HOME COVID-19 waiver period. The updated sample form is valid for use through September 30, 2021, the extended HOME COVID-19 waiver period.

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