Zero Income Statement
Name: __________________________________________ Date: _______________________
Address: ______________________________________________________________________
This self-declaration statement is to certify that I am not receiving income from any source
whatsoever.
• I am not employed through any private or public employer.
• I am not receiving unemployment compensation benefits.
• I am not receiving Social Security, SSI, disability benefits, workmen’s compensation,
veteran’s pension or any type of annuity benefits.
• I am not receiving Public Assistance (PA).
• I am not receiving income from any source (such as interest from bank accounts, rents
from rental property, etc.).
• I am on maternity leave without pay ____ (Check if applicable).
• I do not receive alimony or child support.
• I understand that I must report any change in income status.
I have read and understand the above statements and understand that any misrepresentation
of the above will result in termination of my homeownership incentive.
Note: Regular monetary contributions from friends, relatives, etc. is income and must be
reported. You must obtain a notarized statement of amount received from your contributor.
This form must be notarized in order to be deemed valid.
_________________________________________
Signature
Subscribed to and sworn to this________ day of ______________________________, 20_____.
_________________________________________ Seal:
Notary Public
_________________________________________
Printed Name of Notary
My Commissions Expires: _____________
