Affidavit Of Unemployment

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ATTACHMENT I
Affidavit of Unemployment
Name: ________________________________________
App#: _________________
Development Name: ____________________________________________________________
Please read carefully and complete all statements that apply:
1.
( ) I am currently unemployed but am receiving or eligible to receive unemployment
benefits and/or other compensation based on employment history. I understand that
the collection of unemployment benefits is subject to verification in conjunction with
my application.
My last employer was: ________________________________________________
My last date of employment was : _______________________________________
2.
( ) I am currently unemployed and am NOT eligible to apply for or have exhausted
my unemployment benefits and/or any other type of compensation based on
employment history.
3.
( ) I am currently unemployed, but am receiving income from a source other than
employment (i.e. AFDC, Social Security, SSI, pension). I understand that my
alternative source of income is subject to verification in conjunction with my
application.
4.
( ) I am currently unemployed and am ineligible to receive any federal, city or state
financial assistance.
Under penalty of perjury, I certify that the information presented in this affidavit is true and
accurate to the best of my knowledge. The undersigned further understands that providing
false representations herein constitutes an act of fraud. False, misleading or incomplete
information may result in the termination of the processing of this application.
___________________________________________________
__________________
Signature
Date
Sworn to and subscribed before me on this _________ day of _______, 20__.
___________________________________
Notary Public

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