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Attachment 2 – 24 CFR Part 5 Annual Income Exclusions1.Income from employment of children (including foster children) under the age of 18 years.2.Payments received for the care of foster children or foster adults (usually persons withdisabilities, unrelated to the tenant family, who are unable to live alone).3.Lump-sum additions to family assets, such as inheritances, insurance payments (includingpayments under health and accident insurance and worker’s compensation), capital gains,and settlement for personal or property losses (except as provided in Attachment 1, number5 of Income Inclusions).4.Amounts received by the family that are specifically for, or in reimbursement of, the cost ofmedical expenses for any family member.5.Income of a live-in aide (as defined in 24 CFR 5.403).6.Certain increases in income of a disabled member of qualified families residing in HOMEassisted housing or receiving HOME tenant-based rental assistance (24 CFR 5.671(a)).7.The full amount of student financial assistance paid directly to the student or to theeducational institution.8.The special pay to a family member serving in the Armed Forces who is exposed to hostilefire.9.(a) Amounts received under training programs funded by HUD.(b) Amounts received by a person with a disability that are disregarded for a limited time forpurposes of Supplemental Security Income eligibility and benefits because they are setaside for use under a Plan to Attain Self-Sufficiency (PASS).(c) Amounts received by a participant in other publicly assisted programs that arespecifically for, or in reimbursement of, out-of-pocket expenses incurred (special equipment,clothing, transportation, childcare, etc.) and which are made solely to allow participation in aspecific program.(d) Amounts received under a resident service stipend. A resident service stipend is amodest amount (not to exceed 200 per month) received by a resident for performing aservice for the PHA or owner, on a part-time basis, that enhances the quality of life in thedevelopment. Such services may include, but are not limited to, fire patrol, hall monitoring,lawn maintenance, resident initiatives coordination, and serving as a member of the PHA’sgoverning board. No resident may receive more than one such stipend during the sameperiod of time.(e) Incremental earnings and benefits resulting to any family member from participation inqualifying state or local employment training programs (including training not affiliated with alocal government) and training of a family member as resident management staff. Amountsexcluded by this provision must be received under employment training programs withclearly defined goals and objectives, and are excluded only for the period during which thefamily member participates in the employment training program.10. Temporary, nonrecurring, or sporadic income (including gifts).11. Reparation payments paid by a foreign government pursuant to claims filed under the lawsof that government by persons who were persecuted during the Nazi era.12. Earnings in excess of 480 for each full-time student 18 years old or older (excluding thehead of household or spouse).6

13. Adoption assistance payments in excess of 480 per adopted child.14. Deferred periodic amounts from supplemental security income and social security benefitsthat are received in a lump sum amount or in prospective monthly amounts.15. Amounts received by the family in the form of refunds or rebates under state or local law forproperty taxes paid on the dwelling unit.16. Amounts paid by a state agency to a family with a member who has a developmentaldisability and is living at home to offset the cost of services and equipment needed to keepthe developmentally disabled family member at home.17. Amounts specifically excluded by any other Federal statute from consideration as income forpurposes of determining eligibility or benefits under a category of assistance programs thatincludes assistance under any program to which the exclusions set forth in 24 CFR 5.609(c)apply. A notice will be published in the Federal Register and distributed to housing ownersidentifying the benefits that qualify for this exclusion.Updates will be published and distributed when necessary. The following is a list of incomesources that qualify for that exclusion: The value of the allotment provided to an eligible household under the Food Stamp Act of1977; Payments to volunteers under the Domestic Volunteer Service Act of 1973 (employmentthrough AmeriCorps, VISTA, Retired Senior Volunteer Program, Foster GrandparentsProgram, youthful offender incarceration alternatives, senior companions); Payments received under the Alaskan Native Claims Settlement Act; Income derived from the disposition of funds to the Grand River Band of Ottawa Indians; Income derived from certain sub marginal land of the United States that is held in trust forcertain Indian tribes; Payments or allowances made under the Department of Health and Human Services’ LowIncome Home Energy Assistance Program; Payments received under the Maine Indian Claims Settlement Act of 1980 ( 25 U.S.C.1721); The first 2,000 of per capita shares received from judgment funds awarded by the IndianClaims Commission or the U.S. Claims Court and the interests of individual Indians in trustor restricted lands, including the first 2,000 per year of income received by individualIndians from funds derived from interests held in such trust or restricted lands; Amounts of scholarships funded under Title IV of the Higher Education Act of 1965,including awards under the Federal work-study program or under the Bureau of IndianAffairs student assistance programs; Payments received from programs funded under Title V of the Older Americans Act of 1985(Green Thumb, Senior Aides, Older American Community Service Employment Program); Payments received on or after January 1, 1989, from the Agent Orange Settlement Fund orany other fund established pursuant to the settlement in the In Re Agent Orange productliability litigation, M.D.L. No. 381 (E.D.N.Y.);7

Earned income tax credit refund payments received on or after January 1, 1991, includingadvanced earned income credit payments; The value of any child care provided or arranged (or any amount received as payment forsuch care or reimbursement for costs incurred for such care) under the Child Care andDevelopment Block Grant Act of 1990; Payments received under programs funded in whole or in part under the Job TrainingPartnership Act (employment and training programs for Native Americans and migrant andseasonal farm workers, Job Corps, veterans employment programs, state job trainingprograms and career intern programs, AmeriCorps); Payments by the Indian Claims Commission to the Confederated Tribes and Bands ofYakima Indian Nation or the Apache Tribe of Mescalero Reservation; Allowances, earnings, and payments to AmeriCorps participants under the National andCommunity Service Act of 1990; Any allowance paid under the provisions of 38 U.S.C. 1805 to a child suffering from spinabifida who is the child of a Vietnam veteran; Any amount of crime victim compensation (under the Victims of Crime Act) received throughcrime victim assistance (or payment or reimbursement of the cost of such assistance) asdetermined under the Victims of Crime Act because of the commission of crime against theapplicant under the Victims of Crime Act; and Allowances, earnings, and payments to individuals participating in programs under theWorkforce Investment Act of 1998.HUD Guidebook HUD-1780-CPD, Technical Guide for Determining Income and Allowances forthe HOME Program, Third Edition, January, 20058

Attachment 3Part 5 Annual Income Net Family Asset Inclusions and ExclusionsInclusionsExclusions1. Cash held in savings accounts, checking accounts, safedeposit boxes, homes, etc. For savings accounts, use thecurrent balance. For checking accounts, use the average6-month balance. Assets held in foreign countries areconsidered assets.1. Necessary personal property, except asnoted in number 8 of Inclusions, such asclothing, furniture, cars, and vehiclesspecially equipped for persons withdisabilities.2. Cash value of revocable trusts available to theapplicant.2. Interest in Indian trust lands.3. Equity in rental property or other capital investments.Equity is the estimated current market value of the assetless the unpaid balance on all loans secured by the assetand all reasonable costs (e.g., broker fees) that would beincurred in selling the asset. Under HOME, equity in thefamily’s primary residence is not considered in thecalculation of assets for owner-occupied rehabilitationprojects.4. Cash value of stocks, bonds, Treasury bills, certificatesof deposit, mutual funds, and money market accounts.5. Individual retirement, 401(K), and Keogh accounts(even though withdrawal would result in a penalty).6. Retirement and pension funds.7. Cash value of life insurance policies available to theindividual before death (e.g., surrender value of a wholelife or universal life policy).8. Personal property held as an investment such as gems,jewelry, coin collections, antique cars, etc.9. Lump sum or one-time receipts, such as inheritances,capital gains, lottery winnings, victim’s restitution,insurance settlements and other amounts not intended asperiodic payments.10. Mortgages or deeds of trust held by an applicant.93. Assets not effectively owned by theapplicant. That is, when assets are held in anindividual’s name, but the assets and anyincome they earn accrue to the benefit ofsomeone else who is not a member of thehousehold and that other person isresponsible for income taxes incurred onincome generated by the asset.4. Equity in cooperatives in which the familylives.5. Assets not accessible to and that provideno income for the applicant.

Lead-Based Paint Hazard Reduction ProgramThank you for your interest in the City of Covington Lead-Based Paint Hazard Reduction Program. The followingforms are required:Lead-Based Paint Hazard Reduction Program - Property Information Complete, sign, and submit only one (1) of this form per building, whether it iso Single-family or multi-familyo Owner occupied or rental Include all required attachmentsLead-Based Paint Hazard Reduction Program - Occupant Information(Required for all occupied units, including owner occupied) Complete, sign, and submit this form for each and every occupied unit Additional forms may be copied or requested Include all required attachmentsForms required for a complete application based on type of property:Building OccupancyRental PropertyOwner OccupiedVacant PropertyPropertyInformation FormOne form includingall required attachmentsOne form includingall required attachmentsOne form includingall required attachmentsOccupantInformation FormOne form forEach occupied unit includingall required attachmentsOne form includingall required attachmentsN/ASubmit all required documents to: LEAD-BASED PAINT HAZARD REDUCTION PROGRAMCity of Covington20 West Pike StreetCovington, KY 41011.An application will not be considered complete until all required forms and attachments are received.Notification will be issued once the application has been reviewed.For assistance in completing this application or to schedule an appointment, call: 859-292-2124 or email:aice@covingtonky.gov.

Lead-Based Paint Hazard Reduction ProgramProperty Information – Required for each building.1. PROPERTY TO BE ADDRESSEDStreet Address:Zip:Total # of Units:# of Occupied Units:Occupancy (Check all that apply):Is there a mortgage on the property?Owned By:OwnerTenantYesVacant If Vacant, how long?NoIndividual(s) (Complete Section 2 below) -OR-Business (Skip to Section 3)2. PROPERTY OWNER INFORMATION – INDIVIDUAL(S) *SKIP IF OWNED BY A BUSINESS*Last Name:Married:First Name:YesNo If Yes, Spouse’s Full Name:Home Address:Unit:City:State:Phone:E-mail:Zip:3. PROPERTY OWNER INFORMATION – BUSINESS *SKIP IF OWNED BY AN INDIVIDUAL*Business Name:Tax ID #:Business Address:Unit:City:State:Contact Name:Phone:Zip:Email:If approved, who will sign contract documents?Name:Title:4. PROPERTY MANAGER INFORMATIONProperty Manager other than the Owner?Yes (Complete this section)No (Skip To section 5)Property Manager Name:Phone:5. UNIT INFORMATION:Unit Number# Bedrooms/Unit Square FootageOccupied?E-mail:Unit 1Unit 2/YesUnit 3/NoYesUnit 4/NoYes/NoYesNoPage 1 of 6

6. DISCLAIMER AND OWNER SIGNATURE(S)I certify that all answers are true and complete to the best of my knowledge. I understand thatintentionally false or misleading information submitted on this application may result in beingpermanently banned from the Lead-Based Paint Hazard Reduction Program. Also, Title 18, Section 1001of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowinglyand willingly making a false or fraudulent statement to a department of the Unites States Government.I understand that participation in this program is voluntary. Submission of this application does notguarantee project funding (neither partial nor complete), nor does it provide exemption fromcomplying with any City of Covington, Commonwealth of Kentucky, Housing Authority of Covington,Northern Kentucky Health Department, or any other official orders. I understand that it is theresponsibility of the property owner to remain in compliance with any official orders always andsubmitting this application does not provide exemption from any possible consequences of noncompliance.Owner Name (Please print clearly):Owner Signature:Date:Owner Name (Please print clearly):Owner Signature:Date:*ITEMS REQUIRED TO BE SUBMITTED WITH PROPERTY INFORMATION*All applications must be fully completed, signed, and submitted with the following to be processed:Recorded Property Deed w/ Legal Description – currentCurrent Property Insurance Declarations page (Must have flood insurance if in a flood plain)Most recent water bill for each unit (Payments must be up to date)Most recent utilities bill for each unit (Payments must be up to date)IF there is a MORTGAGE on the property, the following is required:Mortgage Statement, indicating balance, current amount due, and last payment madeIF the building is owned by a BUSINESS, the following is required:Corporate Resolution or official Articles of Incorporation identifying person eligible to executecontract documentsIF the building owner lives out of state and cannot appear in person, the owner MUST appoint a localrepresentative to attend project meetings. In this case, the following is required:Notarized statement providing the local individual with authority to sign and approve the projecton behalf of the ownerIF the property is OCCUPIED, the following is required for each occupied unit:Occupant Information – completed and signed by occupant OR ownerPage 2 of 6

Lead-Based Paint Hazard Reduction ProgramOccupant Information - One form is required for single-family properties.A separate Occupant Information is needed for each unit in a multi-family building.A. HOME ADDRESSStreet AddressZipApt/Unit #FloorOccupant is:OwnerTenantInformation Provided by:B. PRIMARY OCCUPANT INFORMATIONLast Name:First Name:Primary Phone:E-mail:Date of Birth:How long have you lived here?Is English your primary language?YesNoOwnerTenantMy primary language is:C. OCCUPANT FAMILY INFORMATIONHow many people live in the home?Do you receive a Housing Choice Voucher?YesNoNumber living in the home who are:0 to 5 years old?6 to 17 years old?Older than 17 years?Pregnant?Number of children 0 to 5 years old visiting the home more than 6 hours per week?Is your home used to care for children under 6 years of age?YesNoD. RESIDENT/VISITING CHILD INFORMATIONBirthdateVisitorOccupant/Child VisitorFirst & Last NameResidentALL occupants living in home AND children less than 6 years old visiting more than 6 hours a 5.6.* Please specify your race or races from: American Indian/Alaskan Native; Asian; Black/AfricanAmerican; Native Hawaiian/Other Pacific Islander; White; OtherPage 3 of 6

E. OCCUPANT INCOME INFORMATIONProvide the following information for any household members receiving monthly income of any kind(see examples below). Additional members continued on page 5. Wages/TipsSSIDisabilityHouseholdMember NameWork CompChild SupportPension Public AssistanceFoster careChild care income 1.2.3.4.Monthly Wages Other MonthlyIncome(see above) Home businessSide workOccupationSource(s) ofMonthly IncomeTOTAL MONTHLY INCOMEIf no one in your household is receiving any income, please indicate how the household is currentlysupporting itself financially:F. INCOME SIGNATUREI certify under penalty of law that the information contained in this declaration is true, accurate andcomplete to the best of my knowledge. I agree to provide, upon request, documentation on all incomesources. The information provided herein is subject to verification by the United States Department ofHousing and Urban Development at any time, and Title 18, Section 1001 of the U.S. Code states that aperson is guilty of a felony and assistance can be terminated for knowingly and willingly making a falseor fraudulent statement to a department of the Unites States Government.Print NameOwnerSignatureTenantDateSubmit completed forms directly to:LEAD-BASED PAINT HAZARD REDUCTION PROGRAMCity of Covington20 West Pike StreetCovington, KY 41011For assistance in completing this application:Call: 859-292-2124 or email: aice@covingtonky.govPage 4 of 6

HOW DID YOU HEAR ABOUT THE LEAD-BASED PAINT HAZARD REDUCTION PROGRAM?Please answer all that apply:In-person:At st?VisitorOccupant/Child VisitorFirst & Last NameResident*RESIDENT/VISITING CHILD INFORMATION (CONTINUED)*ALL occupants living in this home AND children less than 6 years old visiting more than 6 hours aweek:Hispanic/LatinoRace7.8.9.10.11.12.*OCCUPANT INCOME INFORMATION (CONTINUED)*Provide the following information for any household members receiving monthly income of any kind(see examples below). Wages/TipsSSIDisabilityHouseholdMember NameWork CompChild SupportPension Public AssistanceFoster careChild care income 5.6.7.8.Monthly Wages Other MonthlyIncome(see above) Home businessSide workOccupationSource(s) ofMonthly IncomeTOTAL MONTHLYINCOMEPage 5 of 6

*ITEMS REQUIRED TO BE SUBMITTED WITH OCCUPANT INFORMATION*Provide originals for all household members 18 years and older:St

A conflict of interest exists if an applicant is an employee, agent, consultant, officer, elected or appointed official to the City of Covington, and if the applicant: . retirement funds, pensions, disability or death benefits, and other similar types of periodic receipts, including a lump-sum amount or prospective monthly amounts for the .