10-29-1984 Council Packet - Laserfiche WebLink

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ASSET INFORMATION List the cash value of assets held by all residents of your household. If woney is owed on any item, the value listed should equal the market value of the item minus the amount that is owed. 1. CASH on hand........................................S 2. CASH in checking accounts ...........................S 3. CASH in savings accounts (including those held .....S in trust) 4. Cash value )f Securities or U.S. Savings bonds ...... 5. Pedemption value of life insurance policies ......... 6. Current Market Value of real estate, NOT INCLUDING the property to be improved and up to 2 surrounding acres. Include 100% of the outstanding balance owed to you on property sold on Contract for Deed ... 7. Other personal property (excluding household furnishings. clothing and one personal vehicle) ..... TOTAL ASSETS ....................................... ....S S S S S OFFICE USE ONLY verified assets S $ $ S S S S S Urban Hennepin County or an authorized representative shall have the right to inspect the property to be improved at any time from the date of the Grant upon giving due notice to the occupant(s). Any person who makes a false statement or misrepresentation in connection with the appli- cation for or use of Urban Hennepin County Grant funds shall be subject to a fine or imprisonment, or both, under the provisions of the Minnesota Criminal Code, and/or may be required to return all or part of the Grant Funds to Urban Hennepin County. I, the undersigned, certify subject to penalty under law that the above Information is true and correct to the best of my knowledge and belief, and that the provisions stated are accepted and agreed to. applicant signature date of application Note: All names and financial information provided on this application are considered private data on individuals and are subject to privacy of information provisions, pursuant to State Statute. Su`-{t a copy of the most recent Property Tax Statement with this application.