Property Name:      								Minnesota Housing D#:      

Part I – Applicant/Tenant Income Certification (to be completed, signed, and dated by Head of Household)
You have applied for or currently reside in a rental housing unit located in a property that received or will receive financing from Minnesota Housing. This financing requires us (owner/property manager) to rent units to households with annual incomes that do not exceed certain limits at initial occupancy. If you receive state or federal rental assistance, your income may not be required to fall within these limits. The following information is necessary to determine eligibility.  Note that future increases to your income will not affect your occupancy; income eligibility needs to be met only once. 
Head of Household:	First Name:      	Last Name:      	
Number of persons who will live in the unit:      	
Total gross annual household income of all household members: $     	
I certify to the best of my knowledge that the above information is true and correct. 	
     	     	     	
Signature of Head of Household	Printed Name of Head of Household	Date	

Part II – Unit and Rent Information (to be completed by owner/property representative)	
Unit  #:	     		Number of bedrooms:      		Move-in date:      
	Household does not/will not receive project-based or tenant-based federal or state rental assistance or Housing Support (formerly Group Residential Housing): OR	
	Household receives/will receive project-based or tenant-based federal or state rental assistance or Housing Support. Enter the name of the rental assistance program:      
Date rental assistance begins/began:      	
1.	Amount of monthly rent tenant is responsible to pay: 				$     
2.	Amount of monthly utility allowance for tenant-paid utilities: 			$     
3.	Amount of monthly charges (in addition to rent) that are not optional: 		$     
4.	Amount of monthly rental assistance: 						$     
Total Rent (add lines 1 through 4 above and enter total): 	$     
Part III – Owner/Property Representative Certification

I certify that this household is eligible to occupy a [enter in this field the name of Minnesota Housing program(s) you are certifying this household is qualified for program-assisted unit in accordance with the Minnesota Housing loan documents that financed this property. 
	     	     	
Signature of Owner/Property Representative	Printed Name	Date	
Completed forms must be made available to Minnesota Housing upon request. Retain completed forms in tenant file.