LAKE COUNTY EMERGENCY RENTAL ASSISTANCE
ZERO INCOME CERTIFICATION
Form to be completed by Head of Household and signed by all adult household members if the
household is claiming zero income.
Head of Household: Date:
Applicant: Application Number:
*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 do not individually receive income from any of the following
sources:
a.
Wages from employment (including commissions, tips, bonuses, fees, etc.);
b.
Income from operation of a business;
c.
Rental income from real or personal property;
d.
Interest or dividends from assets;
e.
Social Security payments, annuities, insurance policies, retirement funds, pensions, or death
benefits;
f.
Unemployment or disability payments;
g.
Public assistance payments;
h.
Periodic allowances such as alimony, child support, or gifts received from persons not living
in my household;
i.
Sales from self-employed resources (Avon, Mary Kay, Shaklee, etc.);
j.
Child support or alimony;
k.
Any other source not named above.
*Initials
2.
I/we currently have no income of any ki
nd and there is no imminent change expected in my
financial status or employment status during the next 12 months.
*I
nitials
(For Office Use Only)
IHCDA Compliance Form #27
Revised 1/1/11
Printed Name of Applicant/Tenant
Date
*Signature of Applicant/Tenant
*Signature of Applicant/Tenant
Printed Name of Applicant/Tenant
Date
Date
*Signature of Applicant/Tenant
Printed Name of Applicant/Tenant
*Signature of Applicant/Tenant
Printed Name of Applicant/Tenant
Date
