SELF DECLARATION OF INCOME
Applicant
Household Member
I, ____________________________________________________, hereby certify that my income per
month is ____________ and my total annual income is ____________.
I do not have verification because:
If the total annual household income is less than 50% of the current Federal Poverty Guidelines for this
household size, include a statement from the applicant of how basic living expenses are provided
(food, shelter, transportation, etc.):
Food:
Shelter:
Transportation:
I certify that the information I have disclosed is true and accurate. I understand that intentionally
providing false information to obtain financial assistance is grounds for denial of assistance and may be
grounds for prosecution under Florida Statutes 775.082 or 775.083.
______________________________________ __________________
Applicant Signature Date
______________________________________ __________________
Household Member Signature Date
___________________________________ __________________
Caseworker Signature Date
