Financial- Heinle, Eric (Previous Tenant)

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r...~, ~~ ~~, ~~,~ Oregon Department of 1 ransportation Name:~ , ~~ ~' Social Security Number: S z - Occupation: ~ Telephone: Employer Name: ~ Employer Telephone: Employer Address: ~~ RELOCATION INCOME VERIFICATION Page ~ of ~ Page(s) Each member of the household over 18 years of age must complete this form. CONFIDENTIAL INFORMATION HOUSEHOLD INCOME LAST 12 MONTHS Gross Wages, Commissions, Bonuses, Tips, and Military Pay Net Business Income Retirement Benefits Unemployme~t - Disability Payments Alimony/ Child Support Other: Line A ....................Total HO~JSEHOLD ASSETS $- `~Z1~ . ~v $ $ $ $ $ $ ~ $ `~Zl ~3, 0~ 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 COMPUTATION: 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 File No. Name Secfion Highway County $ FAP No $ $ $ $ $ $ $ $ $ $ $ $ $ $ 3L13,oa $ $ $ Divided by 12 If page 1, enter the totals from the other pages Total of all pages $ ~Zl3,,vo 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 re cement h ing b nefits in a~c dan e with Oregon Departm~nt of Tr p rt~a ~on regulations. ` `'`~ 1 ~` z~ g1 Relocation Agent Date qpplicant p~e Form 102 (1/14/95) RELOCATION