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Boston Planning & Development Agency (“BPDA”)
Affidavit of Eligibility for Deed Restricted Rental Units
(I/We), __________________________________________________________________________________________
Names of Applicant(s)/Tenant(s)
currently residing at __________________________________________________ , Unit _________________
Address
___________________________________________________________, ____________ ________________
City/Neighborhood State Zip Code
( _________ )__________________________, ______________________________________@_____________________,
Telephone E-mail Address
do hereby represent and warrant as follows:
The singular “I” or “my” below shall signify the plural in the case of more than one prospective tenant.
The term “Affidavit” shall include: all terms and guidelines of this Affidavit of Eligibility for Deed Restricted
Rental Units and its attached Appendices, and all supplemental terms and guidelines published on the BPDA
website, bostonplans.org/housing .
1. I understand if I make any material misstatements or omissions herein, or violate the policies
and/or guidelines contained and referenced in this Affidavit, I will be ineligible to rent, purchase
or own this Unit or any unit with a BPDA income restriction presently and in the future, and that
I will be required to vacate the unit if I have already occupied it.
Initials: _________ Initials: _________ Applicant(s)/Tenant(s) must initial or sign as indicated on each page.
2. The Property (leasing/marketing agent to complete this section)
The Unit I intend to rent is located at _______________________________________________________
Development Name
______________________________________________________________________, Unit # ______________
Street Address
The monthly rent of the Unit is: $_________________
The monthly fees for parking and/or other amenities are: $_________________ (if applicable)
The Total Rent is: $_________________ monthly
Revised 11/03/2021
Page 1 of 7
3. Income and Rent Restrictions
I understand the Unit is subject to restrictions contained in an Affordable Rental Housing Agreement
and Restriction (the “Agreement”) which is a public document available through the Suffolk County
Registry of Deeds. I understand I may request a copy of the Agreement from my Landlord.
4. Occupancy Requirement
I understand that I must occupy the Unit within sixty (60) days of signing the lease, and must
continue to occupy it as my principal place of residence continuously for the duration of my
lease. I agree not to lease, sublease, or rent the Unit to anyone in whole or in part for any length
of time, including through services such as, but not limited to, Airbnb. I further understand that
only the household members identified in this Affidavit may occupy the Unit , and that no other
occupants are permitted without prior certification of eligibility by the BPDA* . I understand that
I may be required to provide proof of compliance with this section at any time, and that failure
to furnish such documentation will make me ineligible to continue residing in the Unit.
* Exceptions made for new minor dependent children born to or adopted by a member of the certified household.
5. Students
Applicants must qualify under BPDA’s guidelines for student eligibility as published on the BPDA website at
the time of submission of this Affidavit. See http://www.bostonplans.org/housing/faqs for more information.
For every household member 18 years or older who is a student, I have attached proof of student
status in the form of a letter from the Registrar or other enrollment verification.
6. Household Members
“Household” shall mean all persons whose names will appear on the lease, and all persons who intend to
occupy the Unit as their primary residence. A pregnant individual is considered a single person.
The following includes all persons who intend to occupy the Property including myself .
A
B
C
D
Name
Age
Relationship to
Primary
Applicant/Tenant
Estimated Current
Annualized Gross
Income
Tenant Initials: _________ Revised 11/03/2021
Co-tenant Initials: _________ Page 2 of 7
(Household Members - continued) For purposes of income determination only :
(i) Legally married couples shall both be considered part of the household, even if separated;
Example: A married couple separates, but is not yet divorced. Spouse A applies for the Unit
individually, as its intended sole occupant. Spouse A must provide documentation of both spouses ’
income and assets , even though Spouse B does not intend to lease or occupy the unit.
(ii) The following are not counted as household members (but must be included in the preceding list):
(a) Any person with no employment income who is not immediate family of one or more of
the primary applicants;
(b) Any minor/dependent not listed on the most recent tax return of a primary applicant or
for whom the applicant has not provided documentation of legal custody/guardianship; and
(c) Any person currently employed as a Personal Care Attendant by an applicant with a
disability, and for whom appropriate documentation of such employment is attached.
Example: Four people apply together for the Unit. One of the four has no employment income and is
not an immediate family member of any other person in the household. These four applicants can
apply together, but must be eligible under the BPDA income limit for a three -person household.
7. Income
BPDA eligibility is based on a household’s estimated current annualized income (“ECAI”) , calculated as the
full or gross amount, before deductions, of all taxable and non-taxable income. ECAI is not determined by
past earnings (i.e. as reported on a prior year’s W-2) but is a projection based on current documentation .
Tenant(s)/applicant(s) must disclose the amount and source of all income received by all household
members, including any income that may not be included in the ECAI calculation. See Appendix A for
additional information and conditions for types of income to be considered for eligibility purposes.
a. Taxes
Applicants must provide the two most recent years’ state and federal income tax returns (including any
attachments and amendments) for every household member age 18 years or older. Any household members
who did not file taxes must provide verification of non-filing from the IRS in lieu of the tax returns.
Applicant(s)/tenant(s) are solely responsible for obtaining their own tax documents , and may request
tax return copies or verifications of non-filing by calling the IRS directly or by submitting Form 4506-T to the
IRS. See www.irs.individuals/get-transcript for instructions. Do not attach Form 4506-T to this Affidavit.
Alternatively, in lieu of a verification of non-filing from the IRS, at times when the IRS may be difficult to
contact, applicants with documented Massachusetts residency for the corresponding tax year may obtain a
verification of non-filing from the MA Department of Revenue (DOR) by contacting
taxpayer-records@dor.state.ma.us for a copy.
Attached are the two most recent years’ state and federal income tax returns or verification of
non-filing for every household member age 18 years or older.
Tenant Initials: _________ Revised 11/03/2021
Co-tenant Initials: _________ Page 3 of 7
Any household member who owns a business or holds any material interest or title in a business,
partnership, estates, trusts, or other assets, in whole or in part, must provide the two most recent years’ tax
forms for the entity. This may include Schedules K-1, Forms 990, Forms 1041, Forms 1065, or other forms
filed with any state or the IRS.
b. Wage Income (W-2 Wage Earners) Check all applicable boxes and attach documents as indicated
⬜ Attached are copies of the two most recent consecutive pay stubs from each job for every
household member age 18 years or older.
⬜ A member of my household is aged 18 years or older and is not employed. I have attached a
signed statement from them attesting to this fact.
⬜ A household member is no longer employed at a W-2 job held during the most recent tax year.
I have attached the W-2 with a signed statement of clarification from the household member
including dates of employment.
c. Self-Employment Income (if applicable)
⬜ For every self-employed household member 18 years or older, I have attached a current
year-to-date profit-and-loss statement with supporting documentation for all claims. If the most
recent year’s tax return has not been filed, I have attached a full year’s profit & loss statement
with supporting documentation for that tax year.
Statement must show actual profits and losses, not projected profits and losses.
d. Other Income (if applicable)
⬜ For cash and other earnings not documented by pay stubs or copies of checks, all current year
bank statements are attached along with a corresponding description of the cash/earnings. I
understand that I may be required to provide earlier statements upon request by the BPDA.
Please provide a written explanation for any deposits over $100 that are not from employment.
8. Rent Burden Protections
A household that would pay more than 50% of gross income towards rent will not be eligible for this rental
unit. Exceptions will be made for households with housing vouchers and may also be made for households
receiving a fixed income consisting solely of benefits such as social security, disability benefits, or a fixed
retirement income. Renewing households who do not meet the 50% threshold may be offered a single,
non-recurring one-year grace period, provided that they are in compliance with all other terms of this
Affidavit.
The BPDA reserves the right to withhold confirmation of eligibility for households who do not document
reasonable means to pay the rent or who provide documentation that is insufficient to verify all income and
assets. The landlord may apply a more restrictive minimum income threshold at their discretion.
I have a housing voucher: ⬜ N/A ⬜ Yes/Applicable
Voucher type (Section 8, MRVP, VASH etc.) and Issuing Agency: _______________________________________
Tenant Initials: _________ Revised 11/03/2021
Co-tenant Initials: _________ Page 4 of 7
9. Guarantors and Co-Signers
I understand that co-signers and guarantors are not permitted unless they are co-tenants who will
reside in the unit. I understand that the Total Rent, as defined in Section 2 of this Affidavit, must be paid
solely by members of the household and/or by a housing voucher.
Guarantors include persons who are not members of the applicant household and who do not intend to
occupy the unit, but who make, or state their intention to make, regular and/or substantial monetary
contributions to members of the household.
10. Household Assets
Assets include but are not limited to the following: checking or savings accounts, CDs, money market
accounts, cryptocurrency, other electronic funds, prepaid debit cards, child support cards, Treasury bills,
stocks, bonds, securities, trust funds, pensions, IRAs, other retirement accounts, current assessed value of all
real estate, rental property, and other real estate holdings, all property held as an investment, all business
capital and other business holdings, and safe deposit box contents (include the value).
All accounts must be represented by complete statements, with all pages included, and must be no more
than 60 days old . If a bank account has been closed within the past 60 days, a copy of the final bank
statement showing a zero balance must be submitted.
If a member of the household has disposed of an asset in whole or in part for less than the fair market value
during the past two years, the BPDA will consider the asset as belonging to the household and count its fair
market value towards the asset calculation. Disposal of assets and/or substantial transfers of funds to
individuals not part of the applicant household may be considered as the applicant’s assets towards the asset
limit with a two year look back period. Any lump sum disposal of assets in excess of $5,000 within six months
of applying/recertifying must be accompanied by documentation showing the source and destination of the
lump sum, and the value of the disposed asset may be counted towards the asset limit. However, assets
documented as lost through a foreclosure or court-documented divorce agreement prior to applying may be
excluded, and exceptions may be made for qualified withdrawals from otherwise exempt asset accounts.
Asset Limitation
a. When applying for a unit designated for households at or below 80% of the area median income (AMI),
the combined total assets of t he household cannot exceed $75,000. When applying for a unit designated
for households in income categories greater than 80% AMI, the combined total assets of the entire
household cannot exceed $100,000. The designated asset limit applies at both initial application and any
recertifications thereafter.
b. Assets held in qualified retirement accounts (IRA, 401(k), pension plan, etc.) at least six months prior to
application are exempt from consideration as part of the household’s total assets unless they are being
liquidated in whole or in part. Government-approved college savings accounts and health savings
accounts (HSAs) are also exempt. Supplemental needs trusts may be exempt from the asset cap.
However, documentation of these assets must still be submitted.
Tenant Initials: _________ Revised 11/03/2021
Co-tenant Initials: _________ Page 5 of 7
c. Applicants applying for income restricted rental units may exceed the set forth asset limitations if all of
the household members are age 65 or older or for households with income consisting solely of
retirement and/or disability benefits. In these instances, a household may have combined assets,
including all retirement & exempt accounts up to $250,000.
I have completed the chart below and attached supporting documentation for all assets held by
each household member 18 years of age or older.
Type of Account
or Asset
Bank/company name
& last 4 digits of
account number
Account
Holder’s Name
Balance
Date
Account
Opened
Disclosure: if all assets are not disclosed at the time of application, the household may be denied approval.
Households determined to be ineligible cannot restructure their finances or household composition and
reapply. After an applicant is deemed ineligible for exceeding the income and/or asset limit, there will be a
two-year waiting period to reapply for a unit in the same income category.
11 . Recertifications of Eligibility and Changes in Household Composition
I understand that if I am approved for the Unit, I cannot add a new household member* or
otherwise allow occupancy by persons other than the household members identified in this
Affidavit until and unless I apply for and obtain prior certification of eligibility by the BPDA. I agree
to notify my landlord in advance of any anticipated changes in my household membership.
* Exceptions made for new minor dependent children born to or adopted by a member of the certified household.
I understand that BPDA requires my household to be recertified for continued eligibility at least
annually as a condition of occupancy of the Unit. I agree to submit a new Affidavit of Eligibility and
proof of income and assets at least annually for every year that I continue to occupy the Unit, and
to provide all such documentation as required and by the stated deadline provided by my landlord.
Tenant Initials: _________ Revised 11/03/2021
Co-tenant Initials: _________ Page 6 of 7
I understand that if I do not meet BPDA guidelines at recertification, or if I fail to provide paperwork
in accordance with all requirements and deadlines, I will be ineligible to continue occupying the
Unit, and my landlord will not be authorized to renew my lease or otherwise extend my tenancy.
I further understand that if I am determined to be ineligible at any time during my tenancy, my
lease will not be renewed and I will be required to vacate the Unit when its current lease expires (or
for tenancies at will, no later than the end of the month subsequent to the determination of
ineligibility) with at least 30 days’ notice to my household from the landlord.
12 . I understand that any documents provided to the BPDA will not be returned.
13 . I understand that approval from any source other than the BPDA does not guarantee BPDA income
eligibility certification.
14 . I understand that I may be required by the BPDA, the landlord, or the landlord’s agent(s) to provide
additional information at any point before or after initial certification. I further understand that the
landlord’s recertification and lease records may be audited by the BPDA from time to time.
15. Expiration Date of Income Certification: I understand that a written confirmation of eligibility, to
be provided by the BPDA to my landlord, is required and is valid for 60 days from the date issued.
16. Third-party verification: I authorize the BPDA to verify the information contained in this Affidavit
and obtain additional information regarding me and my household that is pertinent to eligibility for
BPDA income-restricted housing.
17. I agree to all terms and guidelines contained in this Affidavit. I declare under penalties of
perjury that the information provided in this Affidavit of Eligibility is correct, accurate, and
complete in all respects .
Signed on this _____________ day of ______________________________________ , 20 ___________.
Tenant: _____________________________________________ _______________________________________________
Print name Signature
Tenant: _____________________________________________ _______________________________________________
Print name Signature
Co-Tenant/Occupant: _____________________________________ __________________________________________
Print name Signature
Co-Tenant/Occupant: _____________________________________ __________________________________________
Print name Signature
Note: All Leaseholders and unit occupants age 18 years and older must sign above.
Revised 11/03/2021
Page 7 of 7
Appendix A
Income
For income verification purposes, income will be considered in the following ways:
NOT Included
Sometimes Included
Income from employment
of household members
under the age of 18, and
live-in PCAs
Cash payments and other deposits
for services rendered are reviewed
on a case-by-case basis and may
require additional documentation.*
Value of a housing voucher
or other government
benefits such as SNAP (food
stamps) benefits, tax
refunds and credits
Unemployment compensation is not
counted unless the individual has a
minimum two-year history of
seasonal employment along with
receipt of unemployment
compensation
Financial aid, scholarships,
employer-sponsored health
credits (hospital workers
only), employer-paid
reimbursements (travel,
phone, tuition, etc.),
non-monetary employer
benefits, awards, and/or
perks
Documentation of prior years’
earnings typically are required for
verification purposes rather than
ECAI determination; however,
income from self-employment is
calculated as the average of the last
two years’ tax transcripts and the
year-to-date net revenue.
Debt and liabilities (i.e.
student loans, credit cards,
investment losses)
Alimony and/or child support
payments not accompanied by legal
documentation*
Interest, dividends, capital
gains and sales of stocks
and virtual currency
(counted as assets)
Recurring severance payments,
gambling income
* Such payments do not count towards any applicable minimum income guideline.
Any job offers pending currently or at any point prior to certification/recertification must be disclosed. Any
active business license in which a household member is named must also be disclosed.
For self-employed household members, personal expenses, rental payments for a residential address, and
depreciation will not be subtracted when determining self-employment income for income eligibility
purposes. Ride share income will be counted by the gross earnings as documented by the paying entity.
Deposits, purchases, and expenditures wholly inconsistent with reported income and from which the
household makes material gains may make a household’s eligibility indeterminate, and thus ineligible. A
concealed or in any way disguised source of proceeds will make a household ineligible.
Revised 11/03/2021
Appendix B
Required Attachments for Affidavit of Eligibility (Rental Units)
Lottery applicants please see Appendix C for additional required documents.
All applicable items on this list must be included.
Incomplete Affidavits will be returned to the marketing agent and will delay the certification process.
All supporting attachments must be dated within 60 days of submission of the Affidavit.
Project & Unit #:
Affidavit of Eligibility (one per household) completed by all household members 18+
Section 2 (Unit address information & Total Rent) completed by agent
Applicant/tenant initials on pages 1-6 & signature(s) on page 7
Letter from Registrar for students age 18+ (if applicable)
Signed letter from unemployed adults (if applicable)
Two paystubs (current, consecutive)
Self-employed: YTD profit and loss statement
Past 2 years’ tax returns and W2s &/or 1099s for all household members
- Federal taxes
- State taxes
- All W2s (all most recent W2s must have either 2 pay
stubs or an employment clarification letter)
- Did not file taxes? Submit proof of non-filing from the IRS or MA DOR
& send verification to BPDA
Asset statements* must include all pages
- Checking
- Savings (interest/dividends)
- eBanking
- IRA/investment account (interest/dividends)
- 401(k)/pensions (interest/dividends)
- Stocks, investments
Agent’s certification
Proof of lottery preference documents ( lottery only, see appendix C )
Appendix D: Voluntary Race and Ethnicity Reporting form ( optional )
Disclosure of Appearance of Conflict of Interest form, if applicable ( See and complete Appendix E)
* Entire statements must be submitted. All bank statements must be full and complete with all pages
provided. Printed transaction histories are not acceptable; however, printouts of regular monthly
statements in PDF format are acceptable.
Revised 11/03/2021
Appendix C
Required Attachments for Affidavit of Eligibility (Rental Units - lottery)
If applying for preferences:
⬜ Urban Renewal Displacee (This preference is rarely applicable.)
For persons displaced from the specific property and/or displaced from the relevant Urban Renewal Plan
Area by clearance and redevelopment activities carried out by the Boston Redevelopment Authority.
Attach a displacement notice or proof of residency at the time of displacement in the form of utility bills,
voting record, record of birth or other official documentation.
⬜ Boston Resident preference
“Boston Resident” shall mean any individual whose permanent and principal residence, where he or she
normally eats, sleeps, and maintains his or her personal and household effects, is in the City of Boston.
Attach a copy of two (2) utility bills from separate utility companies in your name: electric, oil, gas, phone
(landline or cell phone), cable/satellite. Bills must be dated within 60 days prior to the lottery date, and must
display service address.
If utility bills cannot be provided, applicants must attach (1) a current signed lease and (2) one of the
following documents:
❑ one bill from any of the above utilities
❑ proof of automobile insurance ( showing the address where the car is garaged )
❑ proof of renter’s insurance
❑ proof of voter registration
In lieu of the documentation described above, BPDA may accept an official letter from transitional housing or
a shelter confirming current residency (must be on shelter letterhead and signed by an executive or manager
authorized to act on behalf of the agency) verifying the applicant’s current address.
⬜ Certified Artist preference
“Artist” shall mean an individual who has received a current Mayor’s Office of Arts and Culture Artist
Certificate. This section is applicable only if there are designated artist preference units in the development.
For more information on the City of Boston’s Arts and Culture Artist Certification program, please
visit http://www.boston.gov and search for Artist Certification or call 617-635-4445.
Attached is a copy of the Mayor’s Office of Arts and Culture Artist Certification letter.
⬜ ADA Unit preference
Units built to accommodate persons with certain disabilities, such as those with mobility or auditory features,
may have lottery preferences for applicants whose disabilities correspond with the built features of those
units. The applicant/tenant must attach formal supporting documentation from a licensed professional who
is providing treatment for the household member’s disability. The note need not include personal
information about the diagnosis or condition, but must include evidence of a direct connection between the
disability and the built out features of the unit.
Revised 11/03/2021
Appendix D
Voluntary Race and Ethnicity Reporting
In an effort to better understand who the Boston Planning & Development Agency (“BPDA”) serves in
income-restricted housing, and to provide program level data to the U.S. Department of Housing and Urban
Development, the BPDA requests that all residents of units monitored by the BPDA have the opportunity to
complete this form on race and ethnicity. This information will only be used in aggregate, for the purposes of
reporting and analysis. There is no penalty for persons who do not complete the form.
General Instructions
This form is to be completed by individuals who are seeking to live (applicants) or are currently living
(residents) in deed restricted housing monitored by the BPDA.
Owners and agents are required to offer the applicant/resident the option to complete the form. The form is
to be completed at initial application or at lease signing. In-place tenants must also be offered the
opportunity to complete the form as part of the next interim or annual recertification. Once the form is
completed it need not be completed again unless the head of household changes.
Completing the Form
To complete the form, the response is for the race and ethnicity of the head of household only.
1. The two ethnic categories you should choose from are defined below. You should check one of the two
categories.
a. Hispanic or Latino. A person of Dominican, Puerto Rican, Cuban, Mexican, South or Central
American, or other Spanish culture of origin, regardless of race.
b. Non-Hispanic or Latino. A person not of Dominican, Puerto Rican, Cuban, Mexican, South or
Central American, or other Spanish culture of origin, regardless of race.
2. The five racial categories to choose from are defined below. You should check as many as apply to you.
You may also check “other” and provide additional information.
a. American Indian or Alaska Native. A person having origins in any of the original peoples of North,
Central, and South America, and who maintains tribal affiliation or community attachment.
b. Asian. A person having origins in any of the original peoples of East Asia, Southeast Asia, or the
Indian subcontinent including, for example, Vietnam, China, Taiwan, Cambodia, India, Japan, Korea,
Malaysia, Pakistan, the Philippine Islands, and Thailand.
c. Black or African American. A person having origins in any of the black racial groups of Africa.
d. Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples
of Hawaii, Guam, Samoa, or other Pacific Islands.
e. White. A person having origins in any of the original peoples of Europe, the Middle East (West Asia),
or North Africa.
Revised 11/03/2021
Name of Property: Property Address:
Name of Developer/Property Manager:
Name of Head of Household: Name of Co-Head of Household:
Ethnic Categories
Select One
Hispanic or Latino
Not Hispanic or Latino
Racial Categories
Select All that Apply
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other _____________________________
Head of Household Signature Date
Co-Head of Household Signature Date
Please submit the completed form with the Affidavit of Eligibility.
Revised 11/03/2021
Appendix E
Appearance of Conflict of Interest Disclosure and Restrictions
This Appendix contains requirements applicable only to current and former employees of the City of Boston
and Boston Planning & Development Agency who may be subject to additional requirements under the
Massachusetts Conflict of Interest Law which may affect eligibility. Any applicant household member within
the following list of categories must complete this form and comply with the instructions contained herein.
Check below if you are:
Current or former City of Boston Employee
Immediate Family Member of Current or former City of Boston or BPDA Employee
Not Applicable
Current or former BPDA Employee
Current & Former City of Boston Employees
I understand that if I am currently employed or have been employed by the City of Boston within the
previous 12 months, I may be subject to disclosure and/or other requirements under Massachusetts
Municipal Employee Conflict of Interest Laws. By signing and submitting this application, I affirm that I have
complied with all applicable Massachusetts Municipal Employee Conflict of Interest Laws, including reviewing
Massachusetts Municipal Conflict of Interest Law requirements pertaining to my submission of this
application with my appointing supervisor when applicable as a current or former employee.
Please list the City of Boston Department or Agency in which you are currently or formerly (within the previous 12
months) employed:____________________________________________________________________________________________
Immediate Family Members of Current and Former City of Boston and BPDA Employees
I understand that if a member of my immediate family is currently or formerly employed by the City of
Boston I must disclose that here as a condition of submitting this application.
Please list the name(s), relation(s), and City of Boston Department(s) or Agencies for all current and/or former
immediate family members
Name
Relation
City Department or Agency
A copy of a completed Disclosure of Appearance of Conflict of Interest form must be provided with the
application, showing verification that the Disclosure has been filed with the Boston City Clerk’s Office, and a
copy of the same must also be provided to the applicant/tenant’s (or immediate family member’s) appointing
supervisor employed by the City of Boston.
Revised 11/03/2021
Agent Certification
(Marketing/leasing agent to complete this page)
I hereby certify as follows regarding the attached BPDA Affidavit of Eligibility for Deed Restricted Rental Units
(the “Affidavit”), submitted or filed on behalf of its signatory or signatories (the “Affiant”, comprising all
members age 18+ of the Household as defined therein) in connection with
_____________________________________, ____________________, # ________, Boston ___________ (the “Unit”):
Street Address Building Name (optional) Unit/Apt No. ZIP
1) The Affidavit was completed for the following purpose ( choose one ):
Applicant for Certification of Eligibility of new household (submit to BPDA)
Tenant Recertification of existing household (retain on file in case of audit)
2) I completed all portions of Section 2 of the Affidavit (entitled “The Property”) before providing the
Affidavit to the Affiant.
3) I verified the Affiant’s identity of the basis of the following valid photo identification ( choose all that
apply) :
MA Driver’s License
Other Driver’s License (list state/country): ______________
Other valid photo identification ( explain) : ________________________________________________
I have retained a copy of the photo identification(s) in our files and understand that
I may be required to provide it to the BPDA upon request.
4) I calculated the Affiant’s ECAI*, to be ______________________ and have attached supporting
documentation in the form of:
BPDA Income calculation worksheet
Other calculation record
*(estimated current annualized income, see Section 7 of the Affidavit)
5) I understand that the building’s owner (and/or developer, if applicable) and immediate family
members thereof, including the owner/developer’s agents and employees and immediate family
members thereof, are prohibited from purchasing or renting any BPDA-restricted housing unit in any
project owned or managed by the owner/developer.
Agent Name (print or type): ___________________________________________________________________________
Agent Company:__________________________________________ Agent Phone:______________________________
Agent Email: ___________________________________________________________________________________________
Unit Landlord (if different from Agent Company):_____________________________________________________
Signature: ________________________________________________________ Date:_____________________________
Revised 11/03/2021
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