Fillable Community Action Agency of Northeast Alabama

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Community Action Agency of Northeast Alabama

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Community Action Agency of Northeast Alabama - Declaration of Household Income
Instructions: This form is to be complete by the person applying for assistance if any of the following situations
apply to the applicant and/or any household member age 18 and over for the previous month:
• Had no income and verification cannot be obtained from a government entity such as the Department of
Human Resources, Department of Labor, Public Housing manager, etc.
• Received income from occasional work such as lawn care, house cleaning, babysitting, car repair, etc. when
a receipt book is not maintained.
• Received money from family/friends
• Received income not reported elsewhere.
Applicant’s name (please print): ________________________________________________________
Applicant’s address (please print): ______________________________________________________
Did you or any household member age 18 and over have no income last month? If so, complete
the following for every adult:
Name
How long has this person had no income?
Did you or any household member age 18 and over receive income from occasional work when
a receipt book was not maintained, receive money from family or friends, or receive any
income not reported elsewhere last month? If so, complete the following for you and every
adult:
Name
Amount:
Source of Income:
How do you pay your rent/mortgage? __________________________________________________
How do you pay for food? ____________________________________________________________
How do you pay for your utilities? _____________________________________________________
I certify that the information provided above is true and complete to the best of knowledge. I understand I may be
required to provide of any information given and that providing false information will invalidate this form and may
require the repayment of any assistance received based on the false information. I understand that I am subject to all
applicable Federal or State laws concerning fraud.
Applicant’s Signature: _____________________________________________ Date: ______________
Community Action Agency of
Northeast Alabama
1481 McCurdy Ave S Rainsville, AL 35986 ∙ 256-638-4430
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Community Action Agency of Northeast Alabama

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Completed 1 April 2022

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