Over-Income Verification Form

Please write your full name (first & last)
Please write your address (i.e. 123 Main St. Burlington, VT 05401). Remember to include unit/apartment # if applicable


1. Please check whether your household makes more than or less than 80% of the 2021 area median income (AMI) by first looking over the chart below to determine the income limit for your household size.

2. Then, select one of the options below the chart to verify whether your household makes more than or less than that amount. 

FY21 Income Limit Area

# of Persons Living   in Household

80% Income Limits ($)
Burlington - South Burlington VT Metropolitan Statistical Area (MSA) 1 $60,100
2 $68,650
3 $77,250
4 $85,800
5 $92,700
6 $99,550
7 $106,400
8 $113,300


Select an Option
Please select an option from the list-box and then sign below


Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. The undersigned further understand(s) that providing false representations herein constitutes an act of fraud. False, misleading, or incomplete information may result in the termination of a lease agreement.