Illinois Housing Development Authority
ZERO INCOME CERTIFICATION
Instructions: Complete one form for each household member 18+ years of age who did not receive income.
NAME:
STREET ADDRESS:
CITY:
ZIP:
STATE:
RELA
TIONSHIP TO TRANSACTION
Borrower Co-Borrower Non-Borrowing Spouse HH Member 18+yrs
I ce
rtify that I do not individually receive income, or, have not received income from any of the following
sources outlined below for the period:
Begi
nning On: Ending On (if ongoing write current):
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. Unemployment or disability payments;
e. Public assistance payments;
f. Periodic allowances such as alimony, child support, or gifts received from persons not living in
my household;
g. Social Security payments, annuities, insurance policies, retirement funds, pensions, or death
benefits; h. Veteran's benefits;
i. Supplemental Security Income;
j. Sales from self-employed resources (Avon, Mary Kay, Pampered Chef, Shaklee, etc.);
and/or k. Any other source not named above.
I certify that the information provided above is true, complete, and accurate to the best of my knowledge.
I understand that providing false representations herein may constitute an act of fraud. I acknowledge
that the information provided is being used for the specific purpose of determining whether my household
is eligible to receive assistance through the Illinois Housing Development Authority’s Down Payment
Assistance. I will fully cooperate to obtain or provide any necessary documents to confirm the information
provided.
Signature
Date
ILLINOIS
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