Certification of Zero Income (March 2021)
(To be completed by adult household members only, if appropriate.)
Household Name: __
Property Address:_________________________________________________________
City:______________________________________ State:__________ Zip:___________
1. I, _____________________________ hereby certify that I do not individually receive income from
any of the following sources:
a. Wages from employment (including commissions, tips, bonuses, fees, pay in lieu of vacation
or sick time, profit sharing, etc.);
b. Income from operation of a business;
c. Rental or royalty income from real or personal property, or gain from the sale of a property;
d. Interest or dividends from assets;
e. Social Security payments, annuities, insurance policy benefits, distributions from retirement
funds, pensions, or death benefits;
f. Unemployment or disability payments;
g. Severance pay;
h. Public assistance payments;
i. Periodic allowances such as alimony, child support, or regular periodic gifts received from
persons not living in my household;
j. Veteran’s benefits;
k. Gambling winnings;
l. Any other source not named above.
2. I currently have no income of any kind and there is no imminent change expected in my financial
status or employment status during the next 12 months.
Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my
knowledge. I further understand that providing false representations herein constitutes an act of fraud. I acknowledge the
information provided is being used for the specific purpose of determining eligibility to receive assistance through
the Emergency Rental Assistance Program (ERAP). If requested, I will fully cooperate with any request to provide documents
to verify the information provided within.
Signature of Applicant Printed Name of Applicant Date