Zero Income Affidavit Form printable pdf download

Zero Income Affidavit Form

ZERO INCOME AFFIDAVIT

(To be completed by adult household members only, if appropriate)

Household Name: ___________________________________Unit No: ____________________

Development Name: _________________________________City:_______________________

1. I hereby certify that I do not individually receive income from any of the following sources:

a. Wages from employment (including commissions, tips, bonuses, fees, etc.),

b. Income from operation of a business;

c. Rental income from real or personal property;

d. Interest or dividends from assets;

e. Social Security payments, annuities, insurance policies, retirement funds, pensions, or death

benefits;

f. Unemployment or disability payments;

g. Public assistance payments;

h. Periodic allowances such as alimony, child support, or gifts received from persons living in my

household;

i. Sales from self-employed resources (Avon, Mary Kay, Shaklee, etc.);

j. Any other source not named above.

2. I currently have no income of any kind and there is no imminent change expected in my financial status

or employment status during the next 12 months.

3. I will be using the following sources of funds to pay for rent and other necessities:

_______________________________________________________________________________________

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 here-

in constitutes an act of fraud. False, misleading, or incomplete information may result in the termination of

a lease agreement.

RINTED

AME OF

PPLICANT

ENANT

DATE

IGNATURE OF

PPLICANT

ENANT

DATE

ZERO INCOME AFFIDAVIT

Zero Income Affidavit Form