No Income Declaration Statement 21-22
Child(ren) Name:
*
Parent/Guardian:
*
I
parent/guardian's name
*
,
declare that I am the legal parent/guardian of my child(ren).
I have/had no income due to the following: (Please select one)
*
I am/was in training
I am/was in school
I am/was unemployed/looking for a job
Other (please specify)
Other please explain below.
I have been supporting myself & my family as follows:
*
I certify that this information is true. If any part is false, my participation in this agency’s programs may be terminated and/or I may be subject to legal action.
Parent/Guardian Signature:
*
Clear
Date
*
-
Month
-
Day
Year
Date
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