Zero Income Questionnaire Form
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1Zero Income Questionnaire
____________________________________
____________________________
Tenant Name
Social Security Number
____________________________________________________________________
Address of Unit
To claim zero income in the HUD Section 8 housing program you must have no income from any source except student financial
aid, resident service stipends, adoption assistance payments, earned income for full time students EXCEPT THE HEAD OF
HOUSEHOLD OR SPOUSE, adult foster care payments, compensation from State or local job training programs, and training of
resident management staff, property tax rebates, homecare payments for developmentally disabled children or adult family
members, and deferred periodic payments of supplemental security income and social security benefits that are received in a
lump sum.
Please complete the questions below, sign and date and return to our office if you are claiming zero income for housing benefits.
Failure to do so will result in your losing your housing assistance.
I, as head of household, or any adult member (over the age of 18) living in the above unit, receive income from the following
sources:
Wages, including part time, commissions, and overtime:
Yes ______
No ______
TAF or any other income from SRS:
Yes ______
No ______
Social Security Income, including payments received for children:
Yes ______
No ______
SSI Benefits:
Yes ______
No ______
Pensions:
Yes ______
No ______
Interest or Dividend Income:
Yes ______
No ______
V.A. Benefits:
Yes ______
No ______
Baby-sitting Income:
Yes ______
No ______
Recurring periodic gifts:
Yes ______
No ______
Fees:
Yes ______
No ______
Tips:
Yes ______
No ______
Bonuses:
Yes ______
No ______
Salary from family owned business:
Yes ______
No ______
Net Income from business:
Yes ______
No ______
Annuities:
Yes ______
No ______
Insurance Policies:
Yes ______
No ______
Retirement Funds:
Yes ______
No ______
Disability or Death Benefits:
Yes ______
No ______
Workers Compensation:
Yes ______
No ______
Severance Payments:
Yes ______
No ______
Alimony:
Yes ______
No ______
Child Support:
Yes ______
No ______
Winnings paid in periodic payments:
Yes ______
No ______
Rent Income of any type:
Yes ______
No ______
How will you pay for rent and utilities? _________________________________________________________
How will you pay for food and clothing? ________________________________________________________
How will you pay for medical expenses? ________________________________________________________
How will you pay for your transportation expenses? _______________________________________________
I understand that if I claim zero income for housing assistance, I must complete this form every 60 days and return it to the
housing office. Failure to do so will result in my losing my housing assistance. I agree to notify the housing agency IN WRITING
IMMEDIATELY if the above information changes.
I certify that the above information is correct. Any false statements will result in my losing my housing assistance.
______________________________________________
______________________________________________
Signature
Date
Signature
Date
WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or
misrepresentations to any department or agency of the U.S. as to any matter within its jurisdiction.
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