Pbv Application Packet - Housing Authority Of Snohomish County Page 19

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The Housing Authority of Snohomish County
th
12711 4
Ave. W, Everett, WA 98204
Phone:425-290-8499; Fax: 425-290-5618
ZERO INCOME CERTIFICATION
Head of Household:_____________________________________________________
Family Member with zero income:__________________________________________
1. I certify that I do not receive income from any of the following sources
•
Wages from employment
•
Self-employment or business income
•
TANF, GAU, GAX
•
Unemployment, L & I
•
Social Security payments
•
Pensions, retirement funds, annuities
•
Child support, alimony
•
Interest or dividends from assets
•
Gifts (monetary or non-monetary) from anyone outside my household
•
Panhandling
•
Any other source not listed above
2. I will be using the following sources to pay for rent and other living expenses:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
3. I certify that the information provided is true and accurate to the best of my knowledge.
I understand that misrepresentation or omission of information to the Housing Authority
of my family circumstances or income is cause for termination of my housing assistance.
Signature of family member with zero income: ________________________________
Date: ______________________________

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