Energy Assistance Program Zero Income Affidavit
Name of adult member(s) with Zero Income:
The dates may not be in the 30-day timeframe, but “Last date of Employment” and “Date of Last Pay” must be entered for
each adult with zero income.
1. Have a
ny of the above-listed household members received cash or check(s) as payment for work performed in the
days? *Example: hair styling, babysitting, lawn/snow maintenance, car repair, scrap metal, etc.
□ Yes* □ No Continue to question 2
* If yes, the person is not a Zero Income Adult.
2. Have any of the above-listed household members received any cash gifts in the last 30 days? *Example: A friend or
relative gives you $50 this month as a gift to help with your living expenses.
□ Yes* □ No Continue to question 3
*If yes, this is considered “unearned income”; therefore, the person is not a Zero Income Adult.
3. Have any of the above-listed household members received any loans in the last 30 days? *Example: A friend or relative
loans you money this month to help with your living expenses.
□ Yes* CONTINUE □ No Continue to question 4
*If yes, this is not considered income, but is assumed as a debt to be paid back at a later time; therefore, the recipient may be
considered a Zero Income Adult. Please indicate below the amount of the loan, and the name of the person assisting you, then
continue to question 4.
4. Does any person or agency pay any of your expenses, such as rent, mortgage, utilities, directly to the landlord,
mortgage or utility company? Answer a, b, or c below:
□ b. No - COMPLETE TABLE BELOW- how are you meeting your needs with no income?
□ a. Yes - COMPLETE TABLE BELOW
□ c. All Expenses were covered by household’s recorded income. SKIP TO INITIALS AND SIGNATURES.
For a. or b., if any expenses were not covered by household's recorded income, complete the table below and indicate which
expenses were paid directly and by whom. Include the 30-day expense totals, and explain below how the expenses have been
met in the household (such as SNAP, Section 8, etc.). Indicate the name of the person assisting, and complete the Verification
of Paying Household Bills Affidavit, in addition to the Zero Income Affidavit. If a cash gift is received, see #2 (above).
Name of person assisting directly
*Example: clothing, diapers, cleaning supplies, personal hygiene products, etc.
_I certify the information provided above is true and a complete statement of facts.
______I understand: I may be required to provide proof of any information given. False information will
invalidate this form and may require the return of any benefits received based on the false
______I understand all adult household members are subject to further verification of the income
information provided. This form must be completed in full or my application will be DENIED.
Assistance was needed to fill out this form:
□ Yes □ No
t Signature Date
Intake Worker Signature Date