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Page | 1 <br />Need help? Contact Daniela Bautista-Amick dbautista-amick@southbendin.gov or 574-245- <br />6085 <br />South Bend Lead Protection Program <br /> <br />FORM B – Supporting documents for <br /> <br />About me Supporting documents Directions <br /> <br />1 Check all <br />statements that <br />apply to you. <br />2 Check the documents you need to <br />submit. We accept photos (one-page <br />documents only), electronic, and paper <br />copies. <br />3 Read directions for gathering <br />the right documents. <br /> <br />Income from employment documents <br />If you don’t file taxes or report earnings to the government, you are not eligible for the program <br />because your income cannot be verified. <br />About me Supporting documents Directions <br /> <br /> I worked <br />consistently for the <br />past 2 months. <br /> All pay stubs from the past 2 months If you are paid bi-weekly: <br />• Provide 5 most recent paystubs <br />If you are paid weekly: <br />• Provide 9 most recent paystubs <br /> <br />If you do not have traditional paystubs: <br />• Provide other documents showing <br />income from the past 2 months <br /> <br /> I worked  All pay stubs from the past 12 months. If you do not have traditional paystubs: <br />inconsistently for • Provide other documents showing <br />example, seasonal income from the past 12 months <br />work) in the past 12 <br />months. <br /> <br /> I own my own <br />business or am self- <br />employed. <br /> Form 1040, Schedule C Federal tax return <br /> Verification of Income from Business form <br /> Federal and State tax returns from past 2 <br />years (2022 and 2023) <br /> W-2’s from past 2 years (2022 and 2023 <br /> Copy of earnings from Social Security <br />Administration <br />Your income needs to be the same in <br />each document. Please submit all <br />documents. <br /> <br /> <br /> <br /> <br />Continue to next page <br /> <br />FORM B