Zero Income Declaration Statement
This statement is to verify that the person listed below has had no income for the specified number of months and have been with without income for the reasons specified below.
Parent Name
First Name
Last Name
Parent Email
example@example.com
Child/Participant Name
First Name
Last Name
Number of Months Without Income
Please check the box(es) that apply to you.
Lack of Work
Domestic Violence
Seperations from financial provider
Divorce
Natural Disaster
Homelessness
Other
I do not receive taxable income, but have been able to meet my family's basic needs by:
Document of Assistance:
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Please have a person that is assisting you write a brief statement stating how they are assisting you. Please have them sign and date the statement.
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I hereby provide my consent to contact the third-party in reference to the written verification letter/form provided. I certify that the above information is true. If any part is false, I understand that I may be subject to legal action and that my child's participation in the Early Head Start or Head Start program may be terminated. I also understand that this information will be held in strict confidence and is accessible to me during normal business hours.
Signature
Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: