Self-Employment Income Verification Form printable pdf download

Self-Employment Income Verification Form

Full Name of Applicant or Participant

____________________________________________________________________________

I hereby certify that I, _____________________________________________, received a total of

$____________ for the following work:

_________________________________________________________________________________________________________

I expect to earn the gross amount of $____________ for the coming 12 months beginning

(mm/dd/yyyy) ______________ ending (mm/dd/yyyy) ______________ minus expenses in the

amount of $____________ for the total amount expected to earn of $____________ for the

following work:

_________________________________________________________________________________________________________

I understand that if my actual earnings are different from those reported above, that

I will be required to report any changes to the Housing Authority.

______________________________________________________

__________________

Signature of Applicant or Participant

Date

Note: Florida Law Chapter 409.325 F.S. makes it a crime to knowingly give false

information to get into housing, to get lower rent, or to receive aid or benefits under any

state or federally funded assistance program.

This statement must be notarized and returned to the Gainesville Housing Authority

before certification/re-certification can be completed.

State of Florida, County of

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Self-Employment Income Verification Form