GEORGIA RENTAL ASSISTANCE
RECERTIFICATION BASED ON ANNUAL INCOME
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Please complete one form for each adult household members (age 18 and up) for the
recertification of income based on an annual income calculation. This form should be
completed and uploaded where required. In cases where the household member does
not have income, or is unable to provide documentation of their income, please use the
Income Documentation Waiver form. Note that every adult household member (age 18
and up) MUST complete one of the income recertification forms (Annual or Monthly)
and/or the Income Documentation Waiver form.
Full Name: ____________________________________ Date of Birth: _____/____/_______
Address: ___________________________________________ Apt No._________________
City/State/Zip: _______________________________________
Email Address: _____________________________ Contact Phone No. ________________
Please attach one, or a combination of the following:
• Copy of Form 1040 for most current year as filed with the IRS. For Form 1040, both the
return and any W-2 statement(s) and any 1099 forms must be submitted
• Wage statement, interest statement, or unemployment compensation statement from the
most current tax year
• Receipts from benefits income such as TANF, Social Security, SSI, and SSDI payments.
You may submit a determination letter from one of these programs dated on or after
January 1
st
of the current year.
In signing this certification (including electronic signature) you are acknowledging
that falsification of documents or any material falsehoods or omissions in the Application,
including knowingly seeking duplicative benefits, is subject to state and federal criminal
penalties. You are particularly put on notice that 18 U.S.C. §1001 provides, among other
things, that whoever knowingly and willingly makes or uses a document or writing
containing any false, fictitious, or fraudulent statement or entry, in any matter within the
jurisdiction of any department or agency of the United States will be fined not more than
$10,000 or imprisoned for not more than five years, or both. Moreover, you understand and
accept that you are still bound by all certifications made in the attestation form from the
initial application.
___________________________________ ____________________
Applicant Signature Date
____________________________________ ____________________
Signature of Person Helping Complete Form Date
________________________________________
Printed Name of Person Helping Complete Form
