CASH INCOME CERTIFICATION
Virginia Rent Relief Program
I, , have applied for emergency rental assistance
through the Virginia Rent Relief Program (RRP). For determining monthly income, RRP
must obtain income source documentation for at least the two months prior to the
submission of the application for assistance.
I have stated during this verification process that I do not have income source
documentation (bank statements, paystubs, etc.) from my employer because I receive cash
payment for my income in the amount of $________ each month.
I understand that any misrepresentation of information or failure to disclose
information requested on this form may disqualify me from participation in RRP,
and may be grounds for termination of assistance. WARNING: It is unlawful to
provide false information to the government when applying for federal public or
benefit programs per the Program Fraud Civil Remedies Act of 1986, 31 U.S.C. §§
3801-3812.
I certify that the above information is true and correct.
Signature: Date:
NOTE: If more than one adult member of the household does not have income
source documentation (bank statements, paystubs, etc.), the primary applicant must
certify that those household members also receive cash payments from employer/s.
___________________________________________ ______________________
Name of adult household member with cash income #2 Primary Applicant’s Initials
___________________________________________ ______________________
Name of adult household member with cash income #3 Primary Applicant’s Initials
___________________________________________ ______________________
Name of adult household member with cash income #4 Primary Applicant’s Initials
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