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South Bend Lead Protection Program <br />Page | 2 <br /> <br /> <br />Need help? Contact Daniela Bautista-Amick dbautista-amick@southbendin.gov or 574-245- <br />6085 <br />Income from other sources documents <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 />About me Supporting documents Directions <br /> <br /> I have other forms <br />of income. <br /> All documents showing other forms of <br />income such as: <br />• Child support <br />• Social Security Income (SSI) <br />• Social Security Disability Income <br />(SSDI) <br />• Adoption subsidy <br />• Pension <br />• Alimony <br />• Other (Rental <br />Income) <br />If you receive child support: <br />• Provide document showing last 12 <br />months of payments <br />If you receive Social Security Income <br />(SSI) or Social Security Disability <br />Income (SSDI): <br />• Provide annual benefits letter for the <br />current year <br />If you receive adoption subsidies: <br />• Provide agreement document <br />showing monthly subsidy amount <br />If you receive other forms of income: <br />• Provide documents showing other <br />forms of income <br /> <br /> I do not have <br />income. <br /> Sign Zero Income Form (Form C) If you have no forms of income, you <br />need to confirm that. <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Continue to next page <br />