Fillable UNEMPLOYMENT DECLARATION

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UNEMPLOYMENT DECLARATION

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better places, better lives CUMBERLAND COUNTY HOUSING AUTHORITY
114 N. Hanover St. ▪ Carlisle PA 17013-2445 ▪ www.cchra.com P 717-249-1315 or 1-866-683-5907 F 717-249-5988
UNEMPLOYMENT DECLARATION
Name: _____________________________
Address: _____________________________
_____________________________
Phone Number: _____________________________
I, _____________________________, certify that I am not receiving any unemployment benefits
at this time. I understand that if I begin receiving any type of unemployment benefits, I must
report that to the Housing Authority.
Signature: ___________________________________ Date: _____________
NOTE: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false
statements to any Department or Agency of the United States as to any matter within its
jurisdiction.
July 2010 F:Section8:Forms:Unemployment Self-Declaration
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UNEMPLOYMENT DECLARATION

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Completed 19 May 2021

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