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CITY OF SALEM, MASSACHUSETTS DEPARTMENT OF PLANNING AND COMMUNITY DEVELOPMENT DOMINICK PANGALLO MAYOR TOM DANIEL, AICP DIRECTOR 98 WASHINGTON STREET, 2ND FLOOR ♦ SALEM, MASSACHUSETTS 01970 TELE: [PHONE REDACTED] HOUSING REHABILITATION PROGRAM TENANT CHECKLIST Your landlord has applied for housing rehabilitation assistance. In order for repairs to be undertaken in your building, tenants must meet the income qualifications of the program. Please submit the following documents to our office at the above address. All information will be kept confidential. Thank you for your cooperation. Please contact our office if you have any questions. ❑ Completed Tenant Application with a signed Acknowledgment of Owner’s Application form ❑ Income Documentation* copies of the following that apply to any household member: ❑ Employed: Twelve (12) weeks of pay stubs for all working household members. ❑ Self-employed: Most recent federal tax return, including Schedule C and all attachments. ❑ Unemployed: Three most recent checks and official letter stating start date and amount of assistance. ❑ Social Security: Social Security letter from current year stating benefit amount (including any child benefits). ❑ Public Assistance: Recent checks as well as letter from the agency stating amount of assistance. ❑ Pension/Disability: Company letter from current year stating amount of benefits. ❑ Child Support/ Alimony: ❑ Full Time Adult Students: Court Order or letter from father or ex-spouse stating amount of or weekly payments. Letter from school stating current enrollment status for household members age 18 and over. ❑ Most recent federal tax return (Form 1040 with all schedules and attachments) ❑ Three most recent months of statements for all savings & checking accounts for each household member ❑ Most recent quarterly statements for retirement accounts, CDs, trusts, or other investments *Program eligibility is determined by a projection of gross household income for the coming 12-month period. These programs do not discriminate on the basis of race, color, national origin, gender or gender identity, age, religion, familial status, sexual orientation or disability. These programs are funded through the United States Department of Housing and Urban Development (HUD) Community Block Grant (CDBG), HOME, and MassHousing funds. Updated 5/31/2018