Certification of Income – Self Verification (Earned Income but No Documentation)
This form is to be used if the Household has income but can’t provide documents or other
traditional means of showing income. This form can be uploaded to the “I have other income
documents” section of the application.
Name of Applicant:
Name of Employee (if different from Applicant):
Name of Employer:
Address of Employer:
Employer’s phone: Employer’s email:
Start date: Total Income for the past 12 months:
Are you still employed? ☐ Yes ☐ No If no, end date:
I earned income in the past 12 months from this employer, but cannot document it because:
☐ The business closed due to COVID-19
☐ My pay was received in cash
☐ The records of my payment were lost or destroyed
☐ Other reason:
☐ I affirm that the income information presented above is true and accurate to the
best of my knowledge.
☐ I understand that providing false representations constitutes an act of fraud. False,
misleading, or incomplete information may result in the denial of my Household’s
application, the repayment of any funds received through the CERA program, or other
remedies available under law.
(If Electronically Signed) The typed name below serves as my electronic signature for
the above certification.
Signature of Applicant: Date: _______________
