Non-Employment Certification
Complete every field. Use
0
for numeric fields 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 not currently employed in any capacity nor receiving income from any source, and DO NOT intend to become employed within the next twelve (12) months.
I am not currently employed in any capacity; however I DO receive benefits from (benefit verification required).
Benefits Source
I DO intend to become employed within the next twelve (12) months, but am not currently employed. (Complete Part 2)
I have been offered/promised a job to start within the next twelve (12) months (attach offer letter if available). Anticipated start date: (Complete Part 2)
Anticipated Start Date
PART 2 – Anticipated Income
Employer or Job Type
Gross Wages/Salary ($)
Frequency (select one)
Hourly
Weekly
Bi-Weekly
Semi-Monthly
Monthly
Annually
Other
Other (specify)
Average # of regular hours per week
Signatures (each adult household member declaring non-employment)
+ Add Adult Signature
Printed Name
Typed Signature
Date
Remove
Remove
Submit Certification