Your Income Gross Amount How often received? Example – Retirement Pension $500 Bi-Weekly Your Spouse’s Income Gross Amount How often received? Example – Social Security Retirement $800 Monthly Do you or your spouse receive rent monthly from property? Yes No Do you or your spouse receive money from someone who pays room and board? Yes No Do you or your spouse receive money from irregular income during the year? Yes No Assets You will need to provide proof of all assets you and your spouse own or have an interest in. Examples of assets: Cash Resident Account at Facility Stocks Trust Funds Checking Account Certificate of Deposit (CD) Stock Options Annuities Savings Account IRA, 401K, or 403B Bonds Promissory Note Credit Union Account Keogh Plan Profit Sharing Direct Express Account Money Market Account Deferred Compensation Safe Deposit Box Other Financial Investments Asset Type Name of Account Current Balance Name(s) on Account (see above) Bank or Institution Number or Value Example Checking Any Bank 12345 $500 Assets - Continued Do you or your spouse have any Life Insurance Policies? Yes No If yes, list below. Policy Owner Policy Number Individual(s) Covered Insurance Company Face Value Cash Value
Your Income Gross Amount How often received? Example – Retirement Pension $500 Bi-Weekly Your Spouse’s Income Gross Amount How often received? Example – Social Security Retirement $800 Monthly Do you or your spouse receive rent monthly from property? Yes No Do you or your spouse receive money from someone who pays room and board? Yes No Do you or your spouse receive money from irregular income during the year? Yes No Assets You will need to provide proof of all assets you and your spouse own or have an interest in. Examples of assets: Cash Checking Account Savings Account Credit Union Account Money Market Account Resident Account at Facility Certificate of Deposit (CD) IRA, 401K, or 403B Keogh Plan Deferred Compensation Stocks Stock Options Bonds Profit Sharing Safe Deposit Box Trust Funds Annuities Promissory Note Direct Express Account Other Financial Investments Name(s) on Account Asset Type (see above) Name of Bank or Institution Account Number Current Balance or Value Example Checking Any Bank 12345 $500 Assets - Continued Do you or your spouse have any Life Insurance Policies? Yes No If yes, list below. Policy Owner Policy Number Individual(s) Covered Insurance Company Face Value Cash Value