Usda Income Worksheet Form – Fill Out and Use This PDF

Date of Calculation__________

Total # household members = _________

State:_________________________

County:______________________________

List all non-exempt household income: (Per §1980.347)

Name of household member

Source of income

Monthly income

Annual income

receiving the income

from source

X12

from source

(Actual or Average)

_________________________________________$___________ X12

$___________

_________________________________________$___________ X12

$___________

_________________________________________$___________ X12

$___________

_________________________________________$___________ X12

$___________

_________________________________________$___________ X12

$___________

_________________________________________$___________ X12

$___________

_________________________________________$___________ X12

$___________

_________________________________________$___________ X12

$___________

_________________________________________$___________ X12

$___________

_________________________________________$___________ X12

$___________

Total Gross Household Income

$______________ X12

$______________

Total Monthly

Total Annual

Deductions from Annual Income: (Per § 1980.348) (Use when gross income is above income limit):

(1) Number of Minors living in household: ___X $480.00 (Under age 18)

$_____________

(2) Number of Disabled/Handicapped Adults:___ X $480.00 (18 or over& NOT borrowers) $_____________

(3) Number of full time adult students: ____ X $480.00 (18 or over& NOT borrowers)

$_____________

(4) Elderly Family: (borrower or co-borrower over 62) One time deduction of

$400.00

$_____________

(5) Annual Child Care Expense

$_____________

(6) Medical expenses (Elderly family only. Un-reimbursed >3% gross annual income)

$_____________

TOTAL Annual Deductions (Sum of Line 1 thru Line 6)

$_____________

Adjusted Gross Annual Household Income (Gross income less deductions)

$____________

ADJUSTED COUNTY HOUSEHOLD INCOME LIMIT per Rural Development

$____________

Income limits are available at:

http://www.rurdev.usda.gov/rhs/sfh/sfh%20guaranteed%20loan%20income%20limits.htm

or

http://eligibility.sc.egov.usda.gov

__________________________________

Lender Signature

Date

Copyright © 2009. David Hail, All rights reserved.

1

Phone: 972-365-8099

August 2009

Deductions From

Annual Income

Deduct For:

Do Not Deduct For:__________________________________

$480 for each

(A)

Minors (under 18 years of age)

Applicant/Borrower, Spouse, Foster Children, or

member of the

Children of Non-family members.

family residing in

the household.

(B)

Adults (18 years of age or older)

Applicant/Borrower, Spouse or Non-family members.

(C)

Adults (18 years of age or older)

Applicant/Borrower, Spouse or Non-family members.

who are full-time students.

$400 for elderly

(D) Head, Spouse or Sole Member who

family.

is a senior citizen, disabled or

handicapped and is the applicant/

borrower.

(E)

Two or more unrelated senior

Family, if one or more of those living in the house-

citizens, disabled or handicapped

hold is not a senior citizen, disabled or handicapped.

persons living together, at least one

is the applicant/borrower.

(F)

Survivors of deceased FmHA senior

Survivors after remarriage of the deceased borrowers

citizen, disabled or handicapped

spouse.

borrower who occupied the dwelling

(H) Anticipated expenses paid for care of

minor(s) to enable a member of the

Payments made to dependents of the applicant/

family to further his/her education.

borrower.

Aggregate medical

(I)

Planned general medical and dental

Accumulated bills in excess of planned payments for

expenses of the house-

expenses of an elderly family for the

ensuing 12 months.

hold in excess of 3% of

ensuing 12 months which are not

gross annual income.

covered by insurance (eg., medicines,

medical insurance premiums, costs of

nursing care, payment of accumulated

medical bills, and cost of full-time

nursing or institutional care which

cannot be provided in the home).

(J)

Reasonable attendant care and auxiliary Cost already deducted for same user member of

apparatus and equipment expenses to

elderly family.

enable any handicapped/disabled

member of a household (not just an

elderly family) to be employed.

Copyright © 2009. David Hail, All rights reserved.

2

Phone: 972-365-8099

August 2009