Certification Of Zero Income Form printable pdf download

Certification Of Zero Income Form

CERTIFICATION OF ZERO INCOME

(To be completed by adult household members who are claiming zero income from any source, if appropriate.)

Household Name:

Unit No.

Development Name:

City:

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

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

Income from operation of a business;

Rental income from real or personal property;

Interest or dividends from assets;

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

benefits;

Unemployment or disability payments;

Public assistance payments;

Periodic allowances such as alimony, child support, or gifts received from persons not living

in my household;

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

Any other source not named above.

Choose one:

□ Currently, I have no income of any kind and while I am seeking employment, there is no

definite job offer at this time.

□ Currently, I have no income of any kind and I will not be seeking employment at this time.

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 herein constitutes an act of fraud. False,

misleading or incomplete information may result in the termination of a lease agreement.

Signature of Applicant/Tenant

Printed Name of Applicant/Tenant

Date

Certification of Zero Income (March 2009)

Certification Of Zero Income Form