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C-4: Household Income Survey Forms <br /> Household Income Survey <br /> Residential Address: Survey Number: <br /> 1. Please check the appropriate box regarding the property listed above: <br /> ❑ Primary Home (primary residence or occupied by a seasonal migrant laborer) <br /> ❑ Secondary Home (vacation or seasonal home) <br /> ❑ Rental Home and I am the Owner(Skip sections 2 and 3, answer 4) <br /> ❑ Commercial Property including Short Term Rentals (Skip sections 2-4) <br /> ❑ Vacant Lot(Skip sections 2-4) <br /> ❑ Vacant Home (Skip sections 2-4) <br /> 2. How many people including children and adults <br /> live in this household? <br /> 3. Provide your household income information for the past 12 months below: <br /> Household earnings in wages, salary, commissions, <br /> and bonuses from all jobs of residents 15 and older $ <br /> Net non-farm business, professional practice or <br /> partnership income $ <br /> Net farm income $ <br /> Other earnings (interest, Social Security, public <br /> assistance, retirement plans, etc.) $ <br /> Total Income $ <br /> 4. If this property is a rental and you are the owner, please provide the tenant's name and <br /> mailing address. <br /> Tenant Name: <br /> Tenant Mailing Address: <br /> I hereby certify that the above statements are true and correct to the best of my knowledge. <br /> Printed Name Signature Date <br /> Please return this survey in the enclosed postage-paid envelope <br /> Islander Mobile Home Park MHI Final Report: Prepared by RCAC—October 2022 23 <br />