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Asset Information *Note: An asset is defined as

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Virginia Department of Housing and Community Development | Partners for Better Communities
Main Street Centre | 600 East Main Street, Suite 300 Richmond, VA 23219
www.dhcd.virginia.gov | Phone (804) 371-7000 | Fax (804) 371-7090 | Virginia Relay 7-1-1
Asset Information
*Note: An asset is defined as checking and savings accounts (including IRAs, Keogh accounts. and
Certificates of Deposit) stocks, bonds, trusts, pensions, whole life insurance or other assets and their
value owned by any household member.
1. ☐ I/we do not have any assets at this time (do not check this box if you have entered any numbers
in the table).
Provide totals for each asset for the household.
If the total value of all assets is over $5,000, the most recent statement from each asset must be
attached.
Asset*
Account Value
Monthly Income/Interest on
Account
Checking Account
$
$
Savings Account
$
$
Certificates of Deposit*
$
$
Stocks or Bonds
$
$
IRA/s or Retirement Funds
$
$
Mutual Funds
$
$
Trust Accounts
$
$
Whole or Universal Life Insurance (not Term)
$
$
Personal Property held as an investment
$
$
Real Estate
$
$
Any Assets not listed above
$
$
Total
$
$
Virginia Department of Housing and Community Development | Partners for Better Communities
Main Street Centre | 600 East Main Street, Suite 300 Richmond, VA 23219
www.dhcd.virginia.gov | Phone (804) 371-7000 | Fax (804) 371-7090 | Virginia Relay 7-1-1
(Check either box 2 or box 3 below, not both)
2. ☐ I/we have not sold or given away assets (including cash, real estate, etc.) for less than fair
market value during the past two (2) years.
3. ☐ Within the past two (2) years, I/we have sold or given away assets (including cash, real estate,
etc.) for more than $1,000 below fair market value (FMV).
Asset Value (FMV)
Amount Received
Difference between
FMV and Amount
Received
$
$
$
$
$
$
Total
$
$
$
The monthly income from the net family assets is $ . This amount is included in
total gross household income.
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Completed 10 August 2021

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