Fillable DISCLOSURE OF EXPENSES ZERO INCOME REPORTING Utilities Monthly

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DISCLOSURE OF EXPENSES ZERO INCOME REPORTING Utilities Monthly

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better places, better lives CUMBERLAND COUNTY HOUSING AUTHORITY
114 N. Hanover St. ▪ Carlisle PA 17013-2445 ▪ www.cchra.com P 717-249-1315 or 1-866-683-5907 F 717-249-5988
DISCLOSURE OF EXPENSES
ZERO INCOME REPORTING
Please check any of the following expenses that you pay on a monthly basis:
Utilities Monthly Payment
_____ Electric __________
_____ Natural Gas __________
_____ Propane Gas __________
_____ Fuel Oil __________
_____ Water __________
_____ Sewer __________
Miscellaneous Expenses Monthly Payment
_____ Car Payment __________
_____ Car Insurance __________
_____ Gasoline __________
_____ Cable or Satellite TV __________
_____ Telephone __________
_____ Cell Phone __________
_____ Day Care __________
_____ Rental Centers __________
_____ Internet Service __________
_____ Clothing Expense __________
_____ Smoking Expenses __________
_____ Medical Expenses __________
_____ Groceries (includes food,
paper products, toiletries,
cleaning supplies) __________
If you do not have a car, what means of transportation do you use?
________________________________ Cost: _________________
Please list below any expenses you pay on a monthly basis that are not listed above:
_________________________ Monthly Payment: ___________
_________________________ Monthly Payment: ___________
ON REVERSE, PLEASE LIST ANY SOURCES OF INCOME YOU HAVE THAT ARE USED TO PAY THE ABOVE-
LISTED EXPENSES.
better places, better lives CUMBERLAND COUNTY HOUSING AUTHORITY
114 N. Hanover St. ▪ Carlisle PA 17013-2445 ▪ www.cchra.com P 717-249-1315 or 1-866-683-5907 F 717-249-5988
DISCLOSURE OF INCOME SOURCES
Periodic Gifts from Relatives and Friends:
_____ Amount How often received ________ From whom ______________
_____ Amount How often received ________ From whom ______________
_____Amount How often received ________ From whom ______________
Lump Sum Payments from Insurance Settlements:
_____ Amount When received ________________
Income Tax Refunds:
_____ Amount When received ________________
Please list below any other sources of income that you use to pay your expenses:
______________________________________________________
______________________________________________________
______________________________________________________
I/We hereby certify that the above listed information is accurate and correct to the best of my/our
knowledge. I/We understand that false statements or information are punishable under Federal law. I/We
understand that false statements or information are grounds for termination of housing assistance and
termination of tenancy.
______________________________________________ ________________
Signature of Head of Household Date
______________________________________________ ________________
Signature of Spouse/Co-Head Date
NOTE: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements
to any Department or Agency of the United States as to any matter within its jurisdiction.
July 2009 F:Section8:Forms:Expense Disclosure
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DISCLOSURE OF EXPENSES ZERO INCOME REPORTING Utilities Monthly

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Completed 19 May 2021

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