Self-Employment 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 – Please Complete
Business Name
Business Type
Business Address
Established Date
Have operations been continuous?
Yes
No
PART 2 – Certification Statement
I, (Name), do hereby certify that I am self-employed
My net earnings were ($)
I anticipate my annual earnings for the next calendar year to be ($)
PART 3 – Documentation
I HAVE filed a federal income tax return.
I HAVE NOT filed a federal income tax return. Reason:
Reason (required if not filed)
Type of supporting documentation attached (select all that apply)
IRS Form 1040 (with schedule C)
Financial Statements (audited or unaudited)
IRS Form 1099
Payment Records (bank statements, payee statements, invoices, etc.)
Signatures (each adult household member declaring self-employment)
+ Add Adult Signature
Printed Name
Typed Signature
Date
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