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<br />I. What special housing requirements may be necessary as a result of the <br />disability (such as bath fixtures, ramps, etc.)? Please describe. <br /> <br />7. Using the chart below, please list your gross income (before taxes are taken <br />out) from all sources, such as wages, social security, interest, Veteran's <br />Benefits, child support, etc.). Note: if tenant qualifies as elderly or <br />disabled, income question (#7) need not be answered. <br /> <br />Source Exact Monthly Amount <br />A. Wages from employment (full or part-time) $ <br /> - Is employment seasonal or temporary? DYes DNo <br /> - If yes, please explain: <br />B. Disabilitylretirement benefits <br /> - Social Security $ <br /> - Veterans Administration Benefits $ <br /> - Unemployment Insurance $ <br /> - Workers' Compensation $ <br /> - Company Retirement $ <br /> - Other: $ <br />C. Investment Income <br /> - Interest on Savingsllnvestments $ <br /> - Rental Income $ <br /> - Payments from Real Estate Sale $ <br />D. Other Sources <br /> - Educational Grants/Loans $ <br /> - Assistance from Relatives $ <br /> - Child Support $ <br />TOTAL MONTHLY INCOME $ <br /> <br />8. General Information: <br /> <br />Name/location of employment: <br /> <br />Where do children attend school? <br /> <br />Do you depend on public transportation? D Yes D No <br /> <br />I am aware that the benefits provided to special category tenants in a <br />condominium conversion are based on established eligibility criteria, therefore, I <br />swear/affirm the above statements are true, to the best of my knowledge. <br /> <br />Tenant's Signature <br /> <br />Date <br /> <br />Exhibit 15: Application for Recognition as a Special Category <br />Tenant in a Condominium Conversion <br /> <br />Page 2 of3 <br />