Energy Assistance Program Zero Income Verification Affidavit - Indiana Housing & Community Development Authority

Energy Assistance Program Zero Income Verification Affidavit

This form is to be completed by anyone claiming zero income

Household Member: ______________________________________

Section 1: I received income in the following amount: $_________________ during the following month(s), but there is NO

documentation. (Circle all that apply and write the year above the month).

What is the source of this income?

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Jan

Feb

Mar

Apr

May

June

July

Aug

Sept

Oct

Nov

Dec

(Circle all that apply and write the year

Section 2: I received NO income (See * below for examples) during the following months.

above the month).

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Jan

Feb

Mar

Apr

May

June

July

Aug

Sept

Oct

Nov

Dec

Section 3: State, Federal or other assistance. (List ALL sources and approximate amounts that you received to help you meet your

living expenses over the past 12 months). (For example: Section 8 Housing, money from relatives or other household member,

Township Trustee, food pantry, churches, etc.)

Please explain how you are able to pay the following expenses if claiming zero income for the past 12 months. (i.e., child support,

Housing Authority, odd jobs, spouse works, etc.) Include the amount of assistance received for each category and source.

Rent/Mortgage:

Utilities:

Food:

Other Household

Expenses:

I acknowledge that 18 U.S.C. § 1001, “Fraud and False Statements,” provides among other things, in any matter within the jurisdiction of the executive, legislative, or

judicial branch of the Government of the United States, anyone who knowingly and willfully: (1) falsifies, conceals, or covers up by any trick, scheme, or device a

material fact; (2) makes any materially false, fictitious, or fraudulent statement or representation; or (3) makes or uses any false writing or document knowing the same

to contain any materially false, fictitious, or fraudulent statement or entry; shall be fined under this title, and/or imprisoned for not longer than five (5) years. I certify

that the information provided is true and correct. I understand that by giving false information on this form I am subject to criminal penalties pursuant to IC 35-43-5-3.

I authorize state and federal agencies to verify any of this information and hereby consent to the release of my Indiana Tax Return for this purpose.

__________________________________________________

Date: ____/____/____

Signature of Zero Income Applicant

*Examples of types of income: wages, salaries, commissions, bonuses, profit sharing, cashed out vacation or sick pay, tips, Black Lung Pension Disability payments,

disability payments from insurance, dividends, interest, gambling winnings, pensions, railroad retirement benefits, military allotments, regular life insurance payments,

workers compensation, veterans benefits, unemployment compensation, strike benefits, social security benefits, and royalties.

NOTARY ACKNOWLEDGEMENT (Use for Weatherization Assistance Program Referral ONLY)

WITNESS my hand and seal this ______ day of ___________________ 201___.

County of Residence:

________________

____________________________________

Notary Public -Signature

Commission Expires:

________________

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Notary Public -Printed Name

LSP INTERNAL USE ONLY

Date: ____/____/_____

Application#: _________________

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LSP Representative Signature