Fillable Form to be completed by Head of Household (Department of the Treasury - OCIO)

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Form to be completed by Head of Household (Department of the Treasury - OCIO)

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BROWSE DEPARTMENT OF THE TREASURY - OCIO (DC) FORMS

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LAKE COUNTY EMERGENCY RENTAL ASSISTANCE
INCOME CERTIFICATION
Form to be completed by Head of Household and signed by all adult household members if the
household is verifying undocumented income.
Head of Household: _____________________________ Date: ___________________
Applicant: ______________________________ Application Number: __________
(for Office Use Only)
*Acknowledgement: By typing your initials or name below, you acknowledge and agree that this
represents your signature and you are attesting to all information being provided on this form.
1. I/ we hereby certify that I/ we individually receive income from undocumented sources:
Weekly ____________ or
Monthly ____________ or
Annually ____________
Source of Income
________________________________________________________________________
________________________________________________________________________
__________
Initials
2. I/we currently have income and there is no imminent change expected in my financial
status or employment status during the next 12 months.
__________
Initials
Under penalty of perjury, I certify that the information presented in this certification is true and accurate
to the best of my knowledge. The undersigned further understand(s) that providing false representations
herein constitutes an act of fraud. False, misleading, or incomplete information may result in the
termination of and the required repayment of any and all benefits received through the Indiana
Emergency Rental Assistance Program.
_____________________________ _____________________________ ________________
Printed Name of Applicant/Tenant *Signature of Applicant/Tenant Date
_____________________________ _____________________________ ________________
Printed Name of Applicant/Tenant *Signature of Applicant/Tenant Date
_____________________________ _____________________________ ________________
Printed Name of Applicant/Tenant *Signature of Applicant/Tenant Date
_____________________________ _____________________________ ________________
Printed Name of Applicant/Tenant *Signature of Applicant/Tenant Date
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Form to be completed by Head of Household (Department of the Treasury - OCIO)

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Completed 18 November 2021

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