NO INCOME (ZERO INCOME) STATEMENT

NO INCOME (ZERO INCOME) STATEMENT
Each adult (ages 18+) household member reporting no income (zero income) is required to complete this statement form.
Application #
Name

First NameLast Name
I certify that I have (choose one of the following):
Date last received income/money:

MonthDayYear
Date
Date started to recieve money/income or current date.

MonthDayYear
Date
Indicate the type of income that stopped
Indicate the reason why the income stopped:
I certify that all statements contained on this form and in my application are true. I authorize (AGENCY) to examine my tax return in order to verify my income. I understand that in the case of a fraudulent statement or misstatement of "no income" I may be liable for the full value of any assistance received.
Signature of Person
Date

MonthDayYear
Date
Should be Empty: