Transcend STEM Emergency Solutions Grant Self-Declaration of Zero Unverifiable Income

Applicant Name: First Name* Last Name* Date:Date

All household members over the age of 18 must complete this form if they have no income OR their income has not yet been verified by intake worker. Check only one box and fill out information in that section.

I certify that I DO NOT receive income from any source at this time:

I certify that I DO NOT receive income from any source at this time
Not Applicable
Applicant Signature:   Signature   Date:   Date*

I certify, under penalty of perjury, that I currently receive the income from the following source(s):
I certify, under penalty of perjury, that I currently receive the income from the following source(s)   Not Applicable*

Source:    Name
Amount:   $
Frequency: Every how long

Source:    Name
Amount:    $
Frequency: Every how long

Source:    Name
Amount:   $
Frequency:   Every how long

Applicant Signature:   Signature   Date:   Date

Intake Worker Certification:

I understand that third-party verification is the preferred method of certifying an applicant's income for ESG Homeless Prevention and Rapid-Rehousing assistance. I understand self-declaration is only permitted when I have attempted to but cannot obtain third party verification.

Documentation of attempt to obtain third-party verification:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Intake Worker Name:_______________________________ Date:__________________

Intake Worker Siganture:____________________________

ESG Self-Declaration of Zero or Unverifiable Income