Zero Income Certification
Complete every field. Use
0
or
None
where applicable. Do not leave blanks.
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
Household Member Name
Unit No
Certification Type
Initial
Recertification
If Recertification, effective date is required.
Effective Date (Recertification only)
PART 1 – Income Sources (Yes/No)
Do you currently receive, or anticipate receiving in the next 12 months, income from these sources?
Income Source
Yes / No
Income Source
Yes / No
Wages, Bonuses, Commissions, Tips, etc.
Yes
No
Self-Employment, Gig Income, Direct Sales
Yes
No
Unemployment Benefits
Yes
No
Annuities, Insurance Policies, Stocks, etc.
Yes
No
Workers Compensation
Yes
No
Pensions, IRA, 401K
Yes
No
Disability Payments
Yes
No
Income from Rental Property
Yes
No
Alimony/Child Support
Yes
No
Death Benefits
Yes
No
Social Security/SSI
Yes
No
Work for Cash
Yes
No
Recurring Gift Income
Yes
No
Other
Yes
No
If “Other” is Yes, specify:
PART 2 – Survival Statement
Do you own a vehicle?
No
Yes
Car Payment ($/month)
Insurance ($/month)
Gas/Repairs ($/month)
Source of income for monthly vehicle expenses
Do you have internet at home?
No
Yes
Internet monthly expense ($)
Source of income for internet expenses
Do you have cable/streaming subscriptions at home?
No
Yes
Cable/Streaming monthly expense ($)
Source of income for cable/streaming expenses
Past 30 Days Household Expenses
Enter totals for the past 30 days and the source of income for each.
Expense
Amount ($)
Source of Income
Food
Clothing
Cleaning Supplies
Medical
Home/Cell Phone
Personal Hygiene
Signatures (each adult household member declaring ZERO income)
+ Add Adult Signature
Printed Name
Typed Signature
Date
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