Head of Household 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 benefits;
f. Unemployment or disability payments;
g. Public assistance payments;
h. Periodic allowances such as alimony, child support, or gifts received from persons no
living in my household;
i. Sales from self-employed resources (Avon, Mary Kay, Tupperware, etc.)
j. Any other source not named above.
2. I currently have no income of any kind.
3. I will be using the following sources of funds to pay for rent and other necessities:
____________________________________________________________________
4. I will notify the Cumberland County Housing Authority immediately if any changes occur in my
income (i.e., begin receiving social security, SSI or public assistance benefits; obtain employment;
etc.)
