REV:02/09/2021
PARTICIPANT MONTHLY INCOME VERIFICATION
Participant’s Name: _____________________________________
Some PYN funding requires participants to meet certain program eligibility requirement based on personal
income. Please complete the information below. You
must enter your own total monthly income and then list
the number of family members for yourself, your children, and/or your spouse (if applicable).
*Hint: if you have no income, no children, and are not married, you should enter $0.00 for income and 1 for family
members, check the self-attestation $0 income box, print your name in the self-attestation statement, and then sign
the form.
If you have any income, enter your monthly income amount you earn and add your family members plus yourself if
you have any children or are married, check the box that proves your income and then sign the form.
Calculated Monthly Income: $____________________ Number of Family Members: _____________
☐ Check this box if you indicated self-attest to $0.00 income.
I, (_____________________________________________), do herby attest that the proof of income information
stated above is true, accurate, and complete to the best of my knowledge. I understand that any
intentional omission or misrepresentation may subject me to disqualification form programming.
☐ Check this box if you indicated monthly income above $0.00 and then check the box that supports
your income. You will be asked to upload this document.
☐Paystubs, direct deposit, bank statements,
☐Employer letter or email verifying your employment
☐Unemployment Benefits
☐Social Security, public benefits
Participants Signature: __________________________________________ Date: _________________
click to sign
signature
click to edit
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