Marital Separation Certification
Complete every field. Use
0
for amounts when none apply. Do not use “N/A”.
These forms are complex. Each field must be completed. “N/A” is not acceptable. Use
0
or
None
where appropriate.
Development Name
-- Select Development --
Buen Vecino Housing Complex
Ford City Motor Lofts
Oak Leaf Landings Phase I
Oak Leaf Landings Phase II
St. Cloud Villas Phase I
St. Cloud Villas Phase II
Tracey Manor
Head of Household Name
Unit No
Certification Type
Initial
Recertification
If Recertification, effective date is required.
Effective Date (Recertification only)
PART 1 – Select One Option
I am currently legally separated
from my spouse.
(A copy of legal separation agreement must be attached.)
I am currently, but not legally, separated
from my spouse for the following reason(s):
Case Pending
Financially Not Able
Other
Other (specify)
PART 2 – Select One Option
I am currently receiving, or anticipate receiving, compensation from my spouse during the next 12 months.
Amount ($)
Frequency
Monthly
Quarterly
Annually
Other
Other (specify)
I am not currently, and do not anticipate receiving, any compensation from my spouse during the next 12 months.
Signature
Printed Name
Typed Signature
Date
Submit Certification