Certification of Zero Income (September 2000)
(To be completed by adult household members only, if appropriate.)
ousehold Name:
Unit No.
Development Name:
1. I hereby certify that I do not individually receive income from any of the following sources:
a. Wages from employment (including commissions, tips, bonuses, fees, etc.);
b. Income from operation of a business;
c. Rental income from real or personal property;
d. Interest or dividends from assets;
e. Social Security payments, annuities, insurance policies, retirement funds, pensions, or death
f. Unemployment or disability payments;
g. Public assistance payments;
h. Periodic allowances such as alimony, child support, or gifts received from persons not living
in my household;
i. Sales from self-employed resources (Avon, Mary Kay, Shaklee, etc.);
j. 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 or employment status during the next 12 months.
3. I will be using the following sources of funds to pay for rent and other necessities:
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 representations herein constitutes an act of fraud. False,
misleading or incomplete information may result in the termination of a lease agreement.
Signature of Applicant/Tenant Printed Name of Applicant/Tenant Date