HUD HOME Program Posts Sample Annual Income Self-Certification Form

HUD’s Office of Affordable Housing Programs (OAHP) posted “Sample Self-Certification of Annual Income Form.” The sample form may be used by HOME Investment Partnerships Program (HOME) Participating Jurisdictions (PJs) to document annual income for admissions to Emergency Tenant-Based Rental Assistance (TBRA) Programs or to HOME-Assisted units. The form may be used by PJs for: 1) individuals and families who have lost employment or income either permanently or temporarily due to the coronavirus pandemic, and 2) homeless individuals and families who are applying for admission to a HOME rental unit or a HOME funded emergency Tenant-Based Rental Assistance (TBRA) program.

HUD waived on April 10 the HOME regulation that requires PJs to determine annual household income by examining at least two months of source documentation (see Memo, 4/20 about TBRA and HOME Program). Instead of requiring a review of source documentation, the waiver allows PJs to obtain a written statement of the household’s anticipated annual income and household size, along with a certification that the information is complete and accurate.  

The sample form is intended to be a guide and should be adapted to include a PJ’s policy and procedures regarding income eligibility requirements for emergency TBRA/rental assistance. The form may be filled out between the PJ and the applicant, or by the applicant. Applicants can complete the form using current income and asset information available to them. The income sources listed on the form reflect annual income that is commonly used in HUD’s rental and TBRA programs.

The HOME “Sample Self-Certification of Annual Income Form” is at:

More about the HOME program is on page 5-5 of NLIHC’s 2020 Advocates’ Guide.