ZERO INCOME SELF-ATTESTATION FORM
I understand that providing false statements or false information are grounds for the rejection of my
application for participation in the City of Fort Wayne’s COVID-19 Emergency Rental Assistance
Program. In this form, I certify that I DO NOT receive income from any of the following sources:
• Wages from part-time and/or full-time employment (including tips, bonuses, commissions, etc.)
• Wages from gig work (including gig work for companies such as Uber, Lyft, Instacart, Grubhub,
DoorDash, Shipt, Postmates, Uber Eats, etc.)
• Wages from any work performed as an independent contractor/1099 contractor (ex. Avon, Mary
Kay, Stella & Dot, Primerica, hair stylist, barber, manicurist, babysitter, hair braider, lawn/snow
maintenance, mechanic, etc.)
• Income from the operation of a business
• Unemployment or disability payments
• Supplemental Security Income/Social Security Disability Insurance payments for myself or on
behalf of a minor.
• Income from insurance policies, retirement funds, pensions, death benefits, etc.
• Interest or dividends from assets
• Public assistance payments (ex. general relief funds, Temporary Assistance for Needy Families
(TANF), etc.)
• Rental income from real or personal property
• Allowances from child support, alimony, family support, or monetary gifts on a regular basis
• Any other source of income not listed above
I, , do hereby attest under penalty of perjury that at
(print name here, or the form is invalid)
the time of this application, I DO NOT have income, or I am certifying the period during which
I had no income.
I did not receive any income from ________________ until ___________________.
Date Date
Or
I currently do not have any income, starting from ___________ until now.
Date
I certify the above information is complete and accurate to the best of my knowledge. I understand if I
knowingly and willingly make a false or fraudulent statement that Title 18, Section 1001 of the U.S.
Code states that I will be guilty of a felony and assistance can be terminated. I agree to provide any
additional documentation required by the program to document my/our household income.
Applicant Signature Date
INSTRUCTIONS: This form will need to be completed by every adult (age 18+) in the household that
claims they have zero income, and redone with every application for assistance (if still applicable).
click to sign
signature
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