Financial- Heinle, Eric (Previous Tenant)

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~ 3'~~ ~~ ~ ~ Oregon Deparfinent of Transportation RELOCATION INCOME VERIFICATION Page ~ of ~ Page(s) Each member of the household over 18 vears of aae must comnlete this form Name: . , ~~-~-G cl.~-~ Social Security Number: 5 2 - - Occupation:. ~ Telephone: Employer Name: ,- Employer Telephone: _~ Employer Address: CONFIDENTIAL INFORMATION HOUSEHOLDINCOME LAST 12 MONTHS HO~JSEHOLD ASSETS Gross Wages, Commissions, Bonuses, Tips, and Military Pay $ Net Business Income $ Retirement Benefits $ Unemployment $ Disability Payments $ Alimony/ Child Support $ Other. $ $ Line A ....................Total $ COMPUTATION: File No. Name Section Highway County FAP No Equity-Other Real Estate $ Savings Accounts ~ Stocks and Bonds $ Loans/ Accts Receivabie $ Other Captial $ Investments or Assets $ ' $ . ~ $ Line B...........Total $ INCOME ON ASSETS Interest & Dividends $ Net Income From Rentais g (Reai & Personal) Other: $ $ Line C .....................Total $ 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. tf 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 ~ $ 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 Agenl Date Applicant Date Form 102 (1/14/95) RELOCATION