Wisconsin Emergency Rental Assistance (WERA) Program
One-Month Zero Income Form (ZIF) During the Pandemic
Shaded areas to be completed by WERA agency. Please return to .
1. Last date of employment:
2. Did you receive cash for work in the prior month?
*Example: hair styling, babysitting, lawn/snow maintenance, car repair, etc
□
Yes* □ No
3. List any cash you received from family, friends, or donations in the prior month specified. Please specify if the
cash was received as a loan or gift/donation and from whom:
*If a gift or donation was received, a verbal or written statement is required from the gift giver.
4. Did someone help you pay your bills during the prior month listed above?
If Yes*, complete the following contact information:
*If more than one individual helped, please attach additional sheet of paper.
□
Yes □ No
Name:
Address:
Street City State Zip Code
Phone Number: (type: □ home □ cell □ work)
5. Please list the following monthly expenses and explain how the expenses have been met in the household:
*Example: clothing, diapers, cleaning supplies, personal hygiene products, etc.
Explain how you have paid your monthly bills for the past 30 days:
I certify that the information provided above is true and complete statements of facts. I also understand that I may be required to provide proof of
any information given and that giving false information will invalidate this form and may require the return of any benefits received based on the
false information. I understand that all information and supplemental documentation may be subject to verification.
Signature Date
Updated 3-1-2022
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