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VERIFICATION OF INCOME
INSTRUCTIONS FOR PREPARATION
Purpose:
The form is used to verify the applicant’s income to make feasibility determinations on the applicant’s request for assistance.

Handbook Reference:
3-FLP, 4-FLP, 5-FLP
Number of Copies:
Original only
Signatures Required:
Original by the applicant’s employer or other provider of income information 
Distribution of Copies:
Applicant’s case file
Automation-Related Transactions: (Instructions for writers: provide only the information required, i.e. ADPS TC 3K.  If no automation actions are required, insert N/A)  N/A


FSA completes Part A.
Employer completes Parts B and D and forwards the form directly to the office identified in Part A, item 2.

Other information provider completes Parts C and D and forwards the form directly to the office identified in Part A, Item 2.

Part A – General
Items 1 through 9 completed by FSA.
Field Name /
Item No.
Instruction
1
To
Enter the name and address of employer.
2
From
Enter the name and address of the lender or other loan packager. This item must be completed before sending the form to the employer.
3
Certification 
Read Certification.
4
Name
Enter the name of the Agency Official or Loan Packager processing this form.
5
Title
Enter the title of the Agency Official or Loan Packager processing this form.
6
Signature
Enter the signature of the Agency Official or Loan Packager processing this form.

7
Date
Enter the date the form is signed.

Field Name /
Item No.
Instruction
8
Applicant’s Name and Address
Enter the name and address of the applicant.
9
Statement
Read Statement.

Part B – Verification of Employment
Items 1 through 7 are completed by the employer.
1
Date of employment
Enter the applicant’s date of employment.
2
Position
Enter the applicant’s present position.
3
Probability of continued employment
Enter the applicant’s probability of continuing to be employed.
4
Base Pay
Enter a checkmark in the appropriate box to indicate the applicant’s base pay.  Include the dollar amount next to the box selected.  If “Weekly” is selected, include the number of hours per week.
5
Past Year
Enter the Base Pay, Overtime, Commissions and Bonus amount for the past year.
6
Current Year to Date as of______
Enter the current year to date in the space provided.
Enter the Base Pay, Overtime, Commissions or Bonus amount for the current year to the as of date. 
7
Projected Next Year
Enter the Base Pay, Overtime, Commissions or Bonus amount projected for next year.
Part C – Verification of Other Income
Other providers of information complete Items 1 through 4.
1
Source
Enter the source of any other income received.
2
Frequency
Enter the frequency any other income is received.
3
Amount
Enter the amount of the other income received.
4
Comments
Enter any pertinent comments.


Field Name /
Item No.
Instruction
Part D – Certification
Employers and other providers of information complete Items 2 through 6.
1
Certification
Read certification provided on form.
2
Name
Enter the name of the person who is authorized to complete the form.
3
Title
Enter the title the person who is authorized to complete the form.
4.
Signature
Enter the signature of the person providing employment or income information.
5
Phone Number
Enter the telephone number of the person who completed this form.
6
Date
Enter the date the authorized person signed the form.