Adoi Form – Fill Out and Use This PDF

Alternative Documentation of Income

For Rehabilitation Repayment Agreements

Borrower ID: ___________________		Name: ______________________________________________
Address Line 1:	__________________________________________________________________________
Address Line 2:	__________________________________________________________________________
City:____________________________________________			State: |__|__|	Zip Code: |__|__|__|__|__|
Home Phone: (	)_____________________		Cell Phone: (	)_______________________
Family Size: __________			Email Address:__________________________

Family size includes you, your spouse, and your children (including unborn children who will be born during the year for which you certify your family size), if the children will receive more than half their support from you. It includes other people only if they live with you now, they receive more than half their support from you now, and they will continue to receive this support from you for the year that you certify your family size. Support includes money, gifts, loans, housing, food, clothes, car, medical and dental care, and payment of college costs.

Income: (Include your spouse’s income if you are married and live together)

Taxable Income

			Monthly Average Amount		Provide
	Income Type		Borrower	Spouse	The Following Proof
1.	Employment Income	$		$	Copies of 2 most recent pay stubs
					(Dated within past 90 days)
2.	Worker’s Compensation	$		$	Award letter or pay stub
					(Dated within past 90 days)
3.	Unemployment Benefits	$		$	Award letter or pay stub
					(Dated within past 90 days)
4.	Alimony	$		$	Divorce decree
5.	Other Taxable Income	$		$	Evidence of source and amount
Non-Taxable Income
6.	Child Support	$		$	Divorce decree or Support Order
7.	Social Security	$		$	Benefit statement
8.	Other Non-Taxable	$		$	Evidence of source and amount

฀Check this box if you have no income and are entirely supported by someone other than a spouse. Explain how you are supported in the space below:

I affirm, under penalty of perjury, that the information provided above and in the attached documentation is complete and accurate.

Signed: __________________________________________________________ Date: _____________________

Return this Form to:	CBE Group, Inc.
	PO Box 930
	Waterloo, IA 50704-0930

To expedite processing of the Alternative Documentation of Income, the following return options are available:

∙Scan the completed document and e-mail the form to edmail@cbegroup.com

∙Fax the completed form to (866)912-1302.