Self -Employment /Self- Declaration
of Income Verification
Emergency Rental Assistance
Applicant Name
Case Number
Proof of income must be provided for all household member
s who are age 18 or older. If you do not have documentation
of income, or if a household member has no income, this form must be completed.
Household Member ___________________________________________________________________
Provide a detailed explanation of your source(s) of income prior to COVID-19:
Provide a detailed explanation of how COVID-19 impacted your income:
Provide a detailed explanation of your current source(s) of income:
When was last day worked?
How much is your current weekly income?
What is the last date you received payment from the work described
By Signing below, I certify that the information above is true, accurate and complete: that my household income was impacted by
COVID-19; and that I am unable to provide other proof /documentation to support my previous and /or current income. I am aware that if
this form is incomplete or inaccurate there may be a delay in processing and /or my application may be denied. I am also aware that if I
am approved or denied, or not approved for the correct amount, I have a right to file appeal. I certify under perjury that the above
information is complete, true and accurate to the best of my knowledge. I understand that in accordance with Florida Statute Chapter 817,
providing false information is a misdemeanor in the second degree.
Household Member Signature