City of Pasadena, Texas Community Development Dept. P.O. Box 672 Pasadena, TX 77501
(To be completed by ALL adult household members only, if applicable)
Are you the Head of Household or Household Member? Head of Household Household Member
Program Name: _______________________________________
Name: ______________________________________________________
Home Address: ________________________________________________
Phone Number: ______________ DOB: _____ / _____ / ________
(Driver License or Identification) Number: _____________
*Circle One
Total Household Members: ________: ________ Adults (18 years old and older) ________ Children (17 years old & younger)
*Every adult household member without any income must complete this form.
1. I hereby certify that I do not individually receive income from any of the following sources:
Wages from employment (including commissions, tips, bonuses, fees, etc.);
Income from operation of a business;
Rental income from real or personal property;
Interest or dividends from assets;
Social Security payments, annuities, insurance policies, retirement funds, pensions, or death benefits;
Unemployment or disability payments
Public assistance payments;
Periodic allowances such as alimony, child support, or gifts received from persons not living in my
Sales from self-employed resources (Avon, Mary Kay, Scentsy, etc.);
Any other source not named above.
2. I currently have no income of any kind and there is no imminent change expected in my financial status
during the next 12 months.
Under penalty of perjury, I certify that the information presented in this certification is true and accurate to
the best of my knowledge. The undersigned further understand(s) that providing false representation herein
constitutes an act of fraud. False, misleading or incomplete information may result in termination of federal
Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties.
(18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)
Signature Printed Name Date
Program Staff Use Only:
Reviewed by: _________________________ Date: ___________________
Title: __________________________________