NORTHWEST INDIANA STRUCTURED LIVING INITIATIVE
ZERO INCOME CERTIFICATION
Applicant Name:
Date of Birth:
-
Month
-
Day
Year
Date
Current Address:
Phone Number:
Format: (000) 000-0000.
I hereby certify that I currently have no income from any source.
This information will be used to determine eligibility for housing and supportive services.
I am not currently receiving income from:
Employment Wages
Self-Employment
Social Security Benefits
SSI / SSDI
Veterans Benefits
Pension or Retirement Benefits
Unemployment Benefits
Child Support
TANF
Rental Income
Other Income
If I begin receiving income from any source, I agree to notify the program within ten (10) days.
Applicant Signature:
Date:
-
Month
-
Day
Year
Date
Witness/Staff Signature:
Date:
-
Month
-
Day
Year
Date
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