Financial- Davidson, Wade (previous Tenant)

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°~..~ ~ Oregon Department of Transportation Each member of the household over 18 years of age r Name:~~~ ~ Social Security Number. /~~ J ~- Occup tion: ~ ~"1~ ,~yhLc• Tele hp one: ~`_ Empl yer Name: Employer Telephone: ~ ~ ' ~ ~~O Ti '- ~s ~ Empl er Address: .~ ~~ ~~ • CONFIDENTIAL INFORMATION HOUSEHOLDINCOME LAST 12 NiONTHS HOUSEHOLD ASSETS Gross Wages, Commissions, Bonuses, Tips, and Mi~itary Pay $ Net Business Income $ Retirement Benefits $ Unemployment $ Disability Payments $ Alimony/ Child Support $ Other: $ ~ Line A ....................Total $ COMPUTATION: File No. Name Section Highway co~~ry FAP No Equity-Other Real Estate Savings Accounts Stocks and Bonds Loans/ Accts Receivable Other Captial Investments or Assets Line B...........Total INCOME ON ASSETS Interest & Dividends Net Income From Rentals (Real & Personal) Other: Line C .....................Total $ g $ $ Q~ $ $ $ $ $ $ $ $ $ $ Enter the amount from Line A .................................:.. $ If Line B is over $5,000, enter 10% of Line B. $ If Line B is not over $5,000, enter zero. If Line B is under $5,000, enter amount from Line C $ Total $ Divided by 12 If page 1, enter the totals from the other pages Total of all pages Q $ P I certify that the information stated above is correct. I understand that inquiries may be made to verify this information. The sole purpose of this form is the determination of eligibility for relocation assistance and replacement housing benefits in accordance with Oregon Department of Transportation regulations. Relocation Agent Date Applicam Date ~ RELOCATION INCOME VERIFICATION Page _ of _ Page(s) ~ust complete this form. Form 102 (1/14/95) RELOCATION