Planning & Zoning Commission - 387 (06/13/2023)

HOUSING AFFORDABILITY PLAN 
 
 
Affordable Housing Development on Clark 
Lane 
Waterford, Connecticut 
 
 
 
 
 
 
Submitted by Kingstown Properties, LLC to the Waterford Planning & 
Zoning Commission 
 
 
April 2023 
 
 
 
 
 
 
 
 
 
PREPARED BY: 
Halloran Sage, LLP 
225 Asylum Street 
Hartford, Connecticut 06103 
(860) 522-6103 
 
 

 
 
 
 
 
 
 
 
Introduction 
 
 
Kingstown Properties LLC submits this Housing Affordability Plan for the forty 
seven (47) unit multi-family residential mobile home community located  on a portion of 
the property known as 109R and 131 Clark Lane, Waterford, Connecticut. A description 
of the property is appended hereto as Schedule A. 
 
 
Under this plan, thirty percent (30%) of the residential units at the Community 
will meet the criteria for “affordable housing” as defined in Connecticut General 
Statutes (“C.G.S.”) § 8-30g (“Housing Opportunity Units”). C.G.S. § 8-30g requires that 
fifteen percent (15%)  of the Housing Opportunity Units be affordable for forty (40) 
years to families earning eighty percent (80%) or less of the area or State median 
income, whatever is less, and that fifteen percent (15%) be affordable to families 
earning sixty percent (60%) or less of the area or State median income, whichever is 
less. This Housing Affordability Plan (“Plan”), which is proposed as a condition of site 
plan approval by the Waterford Planning and Zoning Commission (the “Commission”), 
satisfies these requirements and describes how the affordable housing mobile home 
units will be administered . 
 
I. 
Homes Designated for Affordable Housing. 
 
 
Thirty percent (30%), or 15 of the homes of the Community will be designated as affordable 
housing units, as defined by C.G.S. § 8-30g.  The Housing Opportunity Units are identified in 
Schedule B attached hereto. 
 
II. 
Forty (40) Year Period. 
 
 
The Housing Opportunity Units shall be designated as affordable for forty (40) years.  The forty 
(40) year affordability period shall be calculated separately for each Housing Opportunity Unit, 
and the period shall begin on the date of conveyance of such Housing Opportunity Unit from the 
Administrator or its successors or assigns to an eligible purchaser, as hereinafter defined. 
 
III. 
Pro-Rata Construction. 
 
 
The Housing Opportunity Units shall be built on a pro rata basis as construction proceeds.  It is 
the Administrator’s intent, therefore, to build and offer for rent one (1) Housing Opportunity Unit 

 
 
 
 
 
within the time that three (3) total units are built and rented.   
 
IV. 
Nature of Construction of Housing Opportunity Units and Market-Rate Homes. 
 
 
The Housing Opportunity Units shall be constructed in substantial conformance with the site 
plans and floor plans approved in the zoning permits for the Community, as may be modified 
based on the requirements of the Waterford Building Official or other Town staffing is signing off 
on administrative permits or approvals. The specifications for model and housing opportunity 
units are the same as described in Schedule C.  
 
V. 
Entity Responsible for Administration and Compliance. 
 
This Affordability Plan will be administered by Kingstown Properties LLC, or its successors and 
assigns (the “Administrator”). Kingstown Properties LLC hereby represents that its staff has the 
experience necessary to administer this Plan. The principal point of contact under this Plan shall 
be Scott Gladstone. Contact information for the principal point of contact shall be provided to 
the Town of Waterford and Commission prior to the issuance of a Certificate of Occupancy. 
The Administrator shall submit annually a written status report demonstrating compliance with 
affordability and occupancy rules and approval conditions. The role of Administrator may be 
transferred or assigned to another entity, provided that such entity has the experience and 
qualifications to administer this Plan. In the event of any assignment of the role of 
Administrator, Kingstown Properties LLC, or its successor, will provide prior written notice to 
the Commission. 
 
VI. 
Notice of Initial Rental of Housing Opportunity Units. 
 
Except as provided in Section X hereof, the Administrator shall provide notice of the availability 
of each Housing Opportunity Unit for rent (the “Notice of Initial Rental”).  Such notices shall be 
provided, at a minimum, by advertising at least two times in a newspaper of general circulation 
in the Town of Waterford. The Administrator shall also provide such notice to the Commission 
and the Clerk of the Town of Waterford. Such notice shall include a description of the available 
Housing Opportunity unit(s), the eligibility criteria for potential residents, the maximum rental 
price (as hereinafter defined), and the availability of application forms and additional 
information. All such notices shall comply with the federal Fair Housing Act, 42 U.S.C. Section 
3601 et seq. and the Connecticut Fair Housing Act, Conn. Gen. Stat. Sections 46a-64b, 64c 
(together, the “Fair Housing Acts”). 
VII. 
Resident Eligibility. 
 
 
Eligibility of applicants to lease Housing Opportunity Units in the Community shall be determined 
by the Administrator in accordance with this Plan and C.G.S. § 8 -30g, as amended.  
 
VIII. 
Affirmative Fair Housing Marketing Plan. 
 

 
 
 
 
 
The rental of both Housing Opportunity Units and market-rate units in the Community shall be 
publicized, using State regulations for affirmative fair housing marketing programs as guidelines.  
The purpose of such efforts shall be to apprize residents of municipalities of relatively high 
concentrations of minority populations of the availability of such units.  The Administrator shall 
have responsibility for compliance with this section.   
 
 
Using the above-referenced State regulations as guidelines, dissemination of information about 
available affordable and market rate units shall include: 
 
A. 
Analyzing census, Connecticut Department of Economic and Community Development 
town profiles, and other data to identify racial and ethnic groups least likely to apply 
based on representation in Waterford's population, including Asian Pacific, Black, 
Hispanic, and Native American populations. 
 
B. 
Announcements/advertisements in publications and other media that will reach minority 
populations, including newspapers, such as the New London Day or radio stations serving 
Waterford, New London and other towns in the metropolitan statistical area and regional 
planning area, and advertisements or flyers likely to be viewed on public transportation 
or public highway areas. 
 
C. 
Announcements to social service agencies and other community contacts serving low-
income minority families (such as churches, civil rights organizations, the housing 
authority and other housing authorities in towns represented in Waterford’s 
metropolitan statistical area and regional planning agency, legal services organizations, 
etc.). 
 
D. 
Assistance to minority applicants in processing applications. 
 
E. 
Marketing efforts in geographic area of high minority concentrations within the housing 
market area and metropolitan statistical area. 
 
F. 
Beginning affirmative marketing efforts prior to general marketing of units, and repeating 
again during initial marketing and at 50 percent completion. 
 
All notices shall comply with the Fair Housing Acts. 
 
IX. 
Application Process. 
 
 
A family or household seeking to rent one of the Housing Opportunity Units (“Applicant”) must 
complete an application to determine eligibility.  The application form and process shall comply 
with the Fair Housing Act. 
 
 
A. 
Application Form. 
 
The application form shall be provided by the Administrator and shall include an income 
pre-certification eligibility form and an income certification form.  In general, income for 

 
 
 
 
 
purposes of determining an Applicant’s qualification shall include the Applicant family’s 
total anticipated income from all sources for the twelve (12) month period following the 
date the application is submitted (“Application Date”).  If the Applicant’s financial 
disclosures indicate that the Applicant may experience a significant change in the 
Applicant’s future income during the twelve (12) month period, the Administrator shall 
not consider this change unless there is a reasonable assurance that the change will in 
fact occur.  The Applicant’s income need not be re-verified after the time of initial rental.  
In determining what is and is not to be included in the definition of family annual income, 
the Administrator shall use the criteria set forth by HUD and listed on Schedule D, 
attached. 
 
B. 
Applicant Interview. 
 
The Administrator shall interview an Applicant upon submission of the completed 
application.  Specifically, the Administrator shall undertake the following: 
1. Review with the Applicant all the information provided on the application. 
2. Explain to the Applicant the requirements for eligibility, verification procedures, and 
the penalties for supplying false information. 
3. Verify that all sources of family income and family assets have been listed in the 
application.  The term “family” shall be as defined by the Connecticut Agency 
Regulations, Conn. Gen. Stat. § 8-37ee-1, as amended. 
4. Request the Applicant to sign the necessary release forms to be used in verifying 
income.  Inform the Applicant of what verification and documentation must be 
provided before the application is deemed complete. 
5. Inform the Applicant that a certified decision as to eligibility cannot be made until all 
items on the application have been verified. 
6. Review with the Applicant the process and restrictions regarding leasing or 
subleasing. 
C. 
Verification of Applicant’s Income. 
 
Where it is evident from the income certification form provided by the Applicant that the 
Applicant is not eligible, additional verification procedures shall not be necessary.  
However, if the Applicant appears to be eligible, the Administrator shall issue a pre-
certification letter.  The letter shall indicate to the Applicant and the Administrator that 
the Applicant is income eligible, subject to the verification of the information provided in 
the Application.  The letter will notify the Applicant that he/she will have thirty (30) days 
to submit all required documentation. 
 
If applicable, the Applicant shall provide the documentation listed on Schedule E attached 

 
 
 
 
hereto, to the Administrator.  This list is not exclusive, and the Administrator may require 
any other verification or documentation, as the Administrator deems necessary. 
X. 
Prioritization of Applicants for Initial Rental. 
 
 
In the event that the number of qualified Applicants exceeds the number of Housing Opportunity 
Units , then the Administrator shall establish a priority list of applicants based on a “first come, 
first served” basis, subject to the applicant’s income pre-certification eligibility and the 
preferences as established in this Section X.  The Housing Opportunity Units will then be offered 
according to the applicant’s numerical listing.  In the event the Community is built in phases, the 
same procedure shall be held for each phase. 
XI. 
Maximum Initial Rental Price. 
 
 
Calculation of the maximum initial rental price (“Maximum Initial Rental Price”) for a Housing 
Opportunity Unit, so as to satisfy C.G.S. § 8-30g, shall utilize the lesser of the area median income 
for the Town of Waterford or the statewide median income as published by HUD as in effect on 
the day a lease is signed by the lessee of the Housing Opportunity Units (“Resident”). Such income 
shall then be adjusted for household size assuming occupancy by 1.5 persons per bedroom and 
using adjustment formula adopted by State regulations. The Maximum Rental Price shall be 
calculated as follows: 
 
 
 
 
 
 
 
THREE BEDROOM RENTAL UNIT FOR FAMILY EARNING LESS THAN  
EIGHTY PERCENT (80%) OF STATEWIDE MEDIAN INCOME 
Sample Computations 
Area Median Income: 
Based on FY  2022 Data: 
 
1. Determine lower of relevant year (2022)  
$112,600 
area median income for Norwich-New London  
HMFA ($112,600) or statewide median income ($112,600),  
adjusted for family size (family of 4), as published by HUD:                                
 
2. Determine the adjusted income for a household of 4.5 persons 
by calculating 104% of item 1: 
$ 117,104 
 
3. Calculate 80% of item 2: 
$ 93,683 
 
4. Calculate 30% of item 3 representing the maximum portion 
of a family’s income that may be used for housing: 
$ 28,104 
 
5. Divide item 4 by twelve (12) to determine the  
maximum monthly outlay: 
$ 2,342 
 
6. Compare HUD 2022 Fair Market Rents for  
$ 1,939 
 
Norwich- New London HMFA ($1,616) times 120 % 
 
 

 
 
 
 
 
7. Use lesser of calculated maximum monthly  
$   1,939 
 
expense (Item 5) and HUD fair market rent (Item 6) 
 
 
8. Determine by reasonable estimate monthly expenses for heat 
$   125 
 
and utility costs, excluding telephone and cable television 
 
but including any fee required for all tenants (tenant 
 
responsible for such expenses) 
 
 
9. Subtract reasonable monthly expenses (Item 8) from 
$   1,814 
 
maximum housing expense (Item 7) to determine maximum 
 
amount available for rent 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
THREE BEDROOM RENTAL UNIT FOR FAMILY EARNING LESS THAN  
SIXTY PERCENT (60%) OF STATEWIDE MEDIAN INCOME             
 
                         Sample 
Computations 
Area Median Income  
 
 
 
 
 
          Based on FY 2022 Data: 
 
1. Determine lower of relevant year (2022)  
$ 112,600 
area median income for Norwich-New London  
HMFA ($112,600) or statewide median income ($112,600),  
adjusted for family size (family of 4), as published by HUD:                                
 
2. Determine the adjusted income for a household of 4.5 persons 
$ 117,104 
by calculating 104% of item 1: 
 
 
3. Calculate 60% of item 2: 
$ 70,262 
 
4. Calculate 30% of item 3 representing the maximum portion 
$ 21,078 
of a family’s income that may be used for housing: 
 
 
5. Divide item 4 by 12 to determine the  
$ 1,756 
maximum monthly outlay: 
 
 
6. Compare HUD 2022 Fair Market Rents for  
$ 1,616 

 
 
 
 
 
Norwich- New London HMFA  
 
7. Use lesser of calculated maximum monthly  
$ 1,616 
 
expense (Item 5) and HUD fair market rent (Item 6) 
 
 
8. Determine by reasonable estimate monthly expenses for heat 
 
and utility costs, excluding telephone and cable television 
 
but including any fee required for all tenants (tenant 
 
responsible for such expenses) 
$    125 
 
9. Subtract reasonable monthly expenses (Item 8) from 
$ 1,491 
 
maximum housing expense (Item 7) to determine maximum 
 
amount available for rent 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
XIII. 
Principal Residence. 
 
 
Housing Opportunity Units shall be occupied only as a Resident’s principal residence.  Leasing, 
assigning, or subleasing of Housing Opportunity Units by the Resident shall be prohibited.   
 
XIV. 
Requirement to Maintain Condition. 
 
 
All Residents are required to maintain their homes.  The Resident shall not destroy, damage or 
impair the home, allow the home to deteriorate, or commit waste on the home.  When a Housing 
Opportunity Unit is offered for rental, the Administrator may cause the home to be inspected. 
 
XV. 
Change of Income or Qualifying Status of Resident 
 
 
In the event that a Resident’s income changes so as to exceed the qualifying maximum, or if the 
Resident otherwise becomes disqualified, such Resident must provide notice to the 
Administrator within seven (7) days of the disqualification. When a resident becomes 
disqualified, the Administrator shall require the Resident to vacate the Housing Opportunity Unit 
within sixty (60) days. The Administrator (or owner if the Administrator is not the owner) in his 
sole discretion may elect to move the Resident to a market rate apartment unit if the Resident 
satisfies the Administrator’s (or owner’s) normal criteria for such unit.  
 

 
 
 
 
 
XVI. 
Enforcement 
 
 
A violation of this Affordability Plan shall not result in a forfeiture of title, but the Commission 
shall otherwise retain all enforcement powers granted by the Connecticut General Statutes, 
including Section 8-12, which powers include, but are not limited to, the authority, at any 
reasonable time, to inspect the property and to examine the books and records of the 
Administrator to determine compliance of Housing Opportunity Unit with the Incentive Housing 
Statutes, Conn. Gen. Stat. Sections 8-13m, et seq. and such regulations as are adopted pursuant 
thereto. Such records are confidential and not subject to disclosure under the Freedom of 
Information Act. 
 


 
 
 
 
 
SCHEDULE A – PROPERTY DESCRIPTION 
 
A certain tract or parcel of land, together with the improvements thereon, if any, 
situated on the northeasterly side of Clark Lane in the Towns of Waterford and New London, 
County of New London and State of Connecticut, which premises is more particularly 
delineated on a certain map or plan entitled "Boundary Plan Made For Leo & Mary Archambault 
Off Clark Lane Waterford, Conn. Date: December 87 Scale: I" = 80' King & Mullen Land 
Surveyors 152 Route 163 Uncasville, Conn. A87-072-31B", which premises is more particularly 
bounded and described as follows: 
 
 
Beginning at a point in the northeasterly street line of Clark Lane at a northwesterly, 
corner of the herein-described tract and on the dividing line between the herein-described tract 
and land now or formerly of Richard and Grace Lacombe as shown on the above-referenced 
plan; thence running South 00°43' 01” East for a distance of 50.63 feet, bounded southwesterly 
by Clark Lane to a point; thence running North 80'13'41" East for a distance of 103.38 feet, 
bounded southeasterly by land now or formerly of Duillo Tepminesi and Matilda Tepminesi to a 
point; thence running South 04°44'49" East for a distance of 253.93 feet, bounded 
southwesterly in part by said Tepminesi land and in part by land now or formerly of Joseph and 
Margaret Laro to an angle point; thence running South 06°41'47" East for a distance of 400.20 
feet, bounded southwesterly in part by land now or formerly of Joseph and Louise Golombeski, 
in part by land now or formerly of Albert and Thelma Santangelo, in part by land now or 
formerly of William and Sherry White and in part by land now or formerly of Carl D. Sherman to 
an angle point; thence running South 08.04'10" East for a distance of 99.95 feet, bounded 
southwesterly in part by said Sherman land and in part by land now or formerly of Robert and 
Verllie Neller to an angle point; thence running South 08°03'22" East for a distance of 199.90 
feet, bounded southwesterly in part by said Neller land, in part by land now or formerly of 
Richard and Elizabeth Patterson and in part by land now or formerly of Donald and Nellie 
Mackenzie to an angle point; thence running South 08°04'57" East for a distance of 109.99 feet, 
bounded southwesterly in part by said Mackenzie land and in part by land now or formerly of 
Helen Alderman to an angle point; thence running South 09°36'31" East for a distance of 144.90 
feet to an angle point; thence running South 80°23'46" West for a distance of 182.61 feet to a 
point in the northeasterly street line of Clark Lane, the last two courses being bounded 
southwesterly and northwesterly by land now or formerly of Alfred and Severina Pourier, 
thence running South 06°35'48" East for a distance of 50.07 feet, bounded southwesterly by 
Clark Lane to a point; thence running North 80°23'46" East for a distance of 200.57 feet to a 
point; thence running South 09°38'41" East for a distance of 151.12 feet to a point, the last two 
courses being bounded southeasterly and southwesterly by land now or formerly of Alexander 
and Mary Kalamian; thence running North 80°29'03" East for a distance of 1,073.83 feet, 
bounded southeasterly by land now or formerly of the Town of Waterford to a point; thence 
running North 26°34'52" West for a distance of 420.93 feet to an angle point; thence running 
North 24° 28'43" West for a distance of 101.79 feet to a point, the last two courses being 
bounded northeasterly by land now or formerly of the City of New London; thence running 
South 82°31'27" West for a distance of 286.35 feet to an angle point; thence running 
South 81°02'24" West for a distance of 195.40 feet to an angle point; thence running 
South 81°50'56" West for a distance of 251.96 feet to an angle point; thence running 

 
 
 
 
North 09°12'45" West for a distance of 938.50 feet to a point, the last four courses being 
bounded by land now or formerly of the City of New London, and the last seven courses being 
along a stone wall; thence running South 80°13'41" West for a distance of 256.00 feet, bounded 
northwesterly by land now or formerly of Richard and Grace Lacombe to the point and place of 
beginning. 
 
 
 
 
Reference is hereby made to a Warranty Deed from Leo J. Archambault and Mary P.T. 
Archambault to Leo Archambault and Mary Archambault, Trustees of the Leo and Mary 
Archambault Route 32 Real Estate Trust, created pursuant to instrument dated November 4, 
2014, dated August 19, 2015 and recorded August 20, 2015 in Volume 1421, Page 320 of the 
Waterford Land Records.

 
 
 
 
 
SCHEDULE B – IDENTIFICATION OF HOUSING OPPORTUNITY UNITS 
 
The following units are hereby reserved as housing opportunity units in accordance with this 
plan:  
 
Housing Opportunity Units designated for families earning 60% or less of the state or area median 
income: 3, 10, 16, 21, 28, 33, 40, and 46.  
 
Housing Opportunity Units designated for families earning 80% or less of the state or area median 
income: 7, 12, 19, 25, 30, 36, and 43. 
 
These units are distributed throughout the proposed development on both sides of the 
common driveway, and include both gable end to the street units and parallel to the street units.  In 
the event that a designated affordable unit is offered for rent for thirty (30) days or more without a 
qualified tenant entering into a lease agreement, the owner may rent that unit as a market rate unit, 
provided that the very next market rate unit which becomes vacant shall be offered as an affordable 
unit to a qualified buyer.  The goal of this provision is to minimize vacancies while assuring that, over 
time, the number of affordable units remains generally constant at 30% of the total units.


 
 
 
 
 
SCHEDULE C - MINIMUM SPECIFICATIONS FOR MODEL AND HOUSING OPPORTUNITY UNITS 
 
 
 
Minimum   specifications for all mobile manufactured homes are provided by the following federal 
regulations: 
 
 
24 C.F.R. §§ 3280.1 and 
 
24 C.F.R. §§ 3282.554  
 
And by Conn. Gen. Stat. §§ 21-68, which are hereby incorporated by reference. 
 
 
In addition, the manufacturer’s specifications for homes on Clark Lane are provided on the following 
pages. 


 
 
 
 
 
 
SCHEDULE D - DEFINITIONS AND ELEMENTS OF ANNUAL FAMILY INCOME 
 
1. 
Annual income shall be calculated with reference to 24 C.F.R. § 5.609, and includes, but is not 
limited to, the following: 
 
a) The full amount, before any payroll deductions, of wages and salaries, overtime pay, 
commissions, fees, tips, bonuses and other compensation for personal services; 
 
b) The net income from operations of a business or profession, before any capital expenditures 
but including any allowance for depreciation expense; 
 
c) Interest, dividends, and other net income of any kind from real or personal property; 
 
d) The full amount of periodic payments received from social security, annuities, insurance 
policies, retirement funds, pensions, disability or death benefits, or other similar types of 
periodic payments; 
 
e) Payments in lieu of earnings, such as unemployment and disability compensation, worker's 
compensation, and severance pay;  
 
f) Welfare assistance.  If the welfare assistance payments include an amount specifically 
designated for shelter and utilities that is subject to adjustment by the welfare assistance 
agency in accordance with the actual cost of shelter and utilities, the amount of welfare 
assistance to be included as income consists of the following:  
 
(1) The amount of the allowance exclusive of the amounts designated for shelter or utilities, 
plus  
 
(2) The maximum amount that the welfare assistance agency could in fact allow the family 
for shelter and utilities;  
 
g) Periodic and determinable allowances, such as alimony and child support payments, and 
regular contributions or gifts received from persons not residing with the Applicant (e.g. 
periodic gifts from family members, churches, or other sponsored group, even if the gifts are 
designated as rental or other assistance);  
 
h) All regular pay, special pay and allowances of a member of the armed forces; 
 
i) Any assets not earning a verifiable income shall have an imputed interest income using a 
current average annual savings interest rate. 
 
2. 
Excluded from the definition of family annual income are the following:  
 
a) Income from employment of children under the age of 18;  

 
 
 
 
 
b) Payments received for the care of foster children;  
 
c) Lump-sum additions to family assets, such as inheritances, insurance payments, capital 
gains and settlement for personal or property losses;  
 
d) Amounts received that are specifically for, or in reimbursement of, the cost of medical 
expense for any family member;  
 
e) Amounts of educational scholarships paid directly to the student or to the educational 
institution, and amounts paid by the government to a veteran in connection with education 
costs; 
 
f) Amounts received under training programs funded by HUD;  
 
g) Food stamps; and  
 
h) Temporary, nonrecurring or sporadic income (including gifts that are not regular or 
periodic).  
 
3. 
Net family assets for purposes of imputing annual income include the following: 
 
a) Cash held in savings and checking accounts, safety deposit boxes, etc.; 
 
b) The current market value of a trust for which any household member has an interest; 
 
c) The current market value, less any outstanding loan balances of any rental property or 
other capital investment;  
 
d) The current market value of all stocks, bonds, treasury bills, certificates of deposit and 
money market funds;  
 
e) The current value of any individual retirement, 401K or Keogh account; 
 
f) The cash value of a retirement or pension fund which the family member can withdraw 
without terminating employment or retiring;  
 
g) Any lump-sum receipts not otherwise included in income (i.e., inheritances, capital gains, 
one-time lottery winnings, and settlement on insurance claims); 
 
h) The current market value of any personal property held for investment (i.e., gems, jewelry, 
coin collections); and  
 
i) Assets disposed of within two (2) years before the Application Date, but only to the extent 
consideration received was less than the fair market value of the asset at the time it was 
sold. 

 
 
 
 
 
 
4. 
Net family assets do not include the following:  
 
a) Necessary personal property (clothing, furniture, cars, etc.);  
 
b) Vehicles equipped for handicapped individuals;  
 
c) Life insurance policies; 
 
d) Assets which are part of an active business, not including rental properties; and  
 
e) Assets that are not accessible to the Applicant and provide no income to the Applicant. 


 
 
 
 
 
SCHEDULE E - DOCUMENTATION OF INCOME 
 
The following documents shall be provided, where applicable, to the Administrator to determine 
income eligibility: 
 
1. 
Employment Income 
 
 
Verification forms must request the employer to specify the frequency of pay, the effective date 
of the last pay increase, and the probability and effective date of any increase during the next 
twelve (12) months.  Acceptable forms of verification (of which at least one must be included in 
the Applicant file) include: 
 
a) An employment verification form completed by the employer. 
 
b) Check stubs or earnings statement showing Applicant's gross pay per pay period and 
frequency of pay.  
 
c) W-2 forms if the Applicant has had the same job for at least two years and pay increases can 
be accurately projected.  
 
d) Notarized statements, affidavits or income tax returns signed by the Applicant describing self-
employment and amount of income, or income from tips and other gratuities. 
 
2. 
Social Security, Pensions, Supplementary Security Income, Disability Income  
 
a) Benefit verification form completed by agency providing the benefits. 
 
b) Award or benefit notification letters prepared and signed by the authorizing agency.  (Since 
checks or bank deposit slips show only net amounts remaining after deducting SSI or 
Medicare, they may be used only when award letter cannot be obtained.)  
 
c) If a local Social Security Administration (SSA) office refuses to provide written verification, the 
Administrator should meet with the SSA office supervisor.  If the supervisor refuses to 
complete the verification forms in a timely manner, the Administrator may accept a check or 
automatic deposit slip as interim verification of Social Security or SSI benefits as long as any 
Medicare or state health insurance withholdings are included in the annual income. 
 
3. 
Unemployment Compensation 
 
a) Verification form completed by the unemployment compensation agency. 
 
b) Records from unemployment office stating payment dates and amounts. 
 
4. 
Government Assistance  
 

 
 
 
 
a) All Government Assistance Programs.  Agency's written statements as to type and amount 
of assistance Applicant is now receiving, and any changes in assistance expected during the 
next twelve (12) months.  
 
b) Additional Information for "As-paid" Programs:  Agency's written schedule or statement that 
describes how the "as-paid" system works, the maximum amount the Applicant may receive 
for shelter and utilities and, if applicable, any factors used to ratably reduce the Applicant's 
grant. 
 
5. 
Alimony or Child Support Payments 
 
a) Copy of a separation or settlement agreement or a divorce decree stating amount and type 
of support and payment schedules.  
 
b) A letter from the person paying the support.  
 
c) Copy of latest check.  The date, amount, and number of the check must be documented.  
 
d) Applicant's notarized statement or affidavit of amount received or that support payments are 
not being received and the likelihood of support payments being received in the future. 
 
6. 
Net Income from a Business 
 
The following documents show income for the prior years.  The Administrator must consult with 
Applicant and use this data to estimate income for the next twelve (12) months.  
 
a) IRS Tax Return, Form 1040, including any:  
 
(1) Schedule C (Small Business) 
 
(2) Schedule E (Rental Property Income)  
 
(3) Schedule F (Farm Income)  
 
b) An accountant's calculation of depreciation expense, computed using straight-line 
depreciation rules.  (Required when accelerated depreciation was used on the tax return or 
financial statement.)  
 
c) Audited or unaudited financial statement(s) of the business.  
 
d) A copy of a recent loan application listing income derived from the business during the 
previous twelve (12) months.  
 
e) Applicant's notarized statement or affidavit as to net income realized from the business 
during previous years. 
 

 
 
 
 
 
7. 
Recurring Gifts 
 
a) Notarized statement or affidavit signed by the person providing the assistance.  Must give 
the purpose, dates and value of gifts. 
 
b) Applicant's notarized statement or affidavit that provides the information above. 
 
8. 
Scholarships, Grants, and Veterans Administration Benefits for Education 
 
a) Benefactor's written confirmation of amount of assistance, and educational institution's 
written confirmation of expected cost of the student's tuition, fees, books and equipment for 
the next twelve (12) months.  To the extent the amount of assistance received is less than or 
equal to actual educational costs, the assistance payments will be excluded from the 
Applicant's gross income.  Any excess will be included in income.  
 
b) Copies of latest benefit checks, if benefits are paid directly to student.  Copies of cancelled 
checks or receipts for tuition, fees, books, and equipment, if such income and expenses are 
not expected to change for the next twelve (12) months.  
 
c) Lease and receipts or bills for rent and utility costs paid by students living away from home. 
 
9. 
Family Assets Currently Held 
 
 
For non-liquid assets, collect enough information to determine the current cash value (i.e., the 
net amount the Applicant would receive if the asset were converted to cash).  
 
a) Verification forms, letters, or documents from a financial institution, broker, etc. 
 
b) Passbooks, checking account statements, certificates of deposit, bonds, or financial 
statements completed by a financial institution or broker.  
 
c) Quotes from a stock broker or realty agent as to net amount Applicant would receive if 
Applicant liquidated securities or real estate.  
 
d) Real estate tax statements if tax authority uses approximate market value. 
 
e) Copies of closing documents showing the selling price, the distribution of the sales proceeds 
and the net amount to the borrower. 
 
f) Appraisals of personal property held as an investment.  
 
g) Applicant's notarized statements or signed affidavits describing assets or verifying the 
amount of cash held at the Applicant's home or in safe deposit boxes. 
 

 
 
 
 
10. 
Assets Disposed of for Less Than Fair Market Value ("FMV") During Two Years Preceding 
Application Date  
 
a) Applicant's certification as to whether it has disposed of assets for less than FMV during the 
two (2) years preceding the Application Date.  
 
b) If the Applicant states that it did dispose of assets for less than FMV, then a written 
statement by the Applicant must include the following: 
 
(1) A list of all assets disposed of for less than FMV,  
 
(2) The date Applicant disposed of the assets,  
 
(3) The amount the Applicant received, and  
 
(4) The market value to the asset(s) at the time of disposition. 
 
11. 
Savings Account Interest Income and Dividends  
 
a) 
Account statements, passbooks, certificates of deposit, etc., if they show enough 
information and are signed by the financial institution. 
 
b) 
Broker's quarterly statements showing value of stocks or bonds and the earnings credited 
the Applicant.  
 
c) 
If an IRS Form 1099 is accepted from the financial institution for prior year earnings, the 
Administrator must adjust the information to project earnings expected for the next twelve 
(12) months. 
 
12. 
Rental Income from Property Owned by Applicant 
 
 
The following, adjusted for changes expected during the next twelve (12) months, may be used:  
 
a) IRS Form 1040 with Schedule E (Rental Income).  
 
b) Copies of latest rent checks, leases, or utility bills.  
 
c) Documentation of Applicant's income and expenses in renting the property (tax statements, 
insurance premiums, receipts for reasonable maintenance and utilities, bank statements or 
amortization schedule showing monthly interest expense).  
 
d) Lessee's written statement identifying monthly payments due the Applicant and Applicant's 
affidavit as to net income realized. 
 

 
 
 
 
 
13. 
Full-Time Student Status  
 
a) Written verification from the registrar's office or appropriate school official. 
 
b) School records indicating enrollment for sufficient number of credits to be considered a full-
time student by the schoo