Certification of Income/Residency Form

Income/Residency Certification

City of Dallas ESG Program: Income/Residency Certification
Case No./Name:
Date:*
MM slash DD slash YYYY
Applicant Email Address:
Income Certification*
I, the Applicant, hereby certify that all sources of income/benefits for my household are shown below. I have attached documentation for each item.
Indicate the amount and frequency of each payment below:
Employment income (salary, wages, tips, etc) for Applicant:
Employment income (salary, wages, tips, etc) for Adult Household Member:
Social Security for Applicant:
Social Security for Adult Household Member:
Annuities/Insurance Policies for Applicant:
Annuities/Insurance Policies for Adult Household Member:
Pension/Retirement for Applicant:
Pension/Retirement for Adult Household Member:
Disability Compensation for Applicant:
Disability Compensation for Adult Household Member:
Unemployment Compensation for Applicant:
Unemployment Compensation for Adult Household Member:
Workers Compensation for Applicant:
Workers Compensation for Adult Household Member:
Severance Pay for Applicant:
Severance Pay for Adult Household Member:
Welfare Assistance (exclude food stamps) for Applicant:
Welfare Assistance (exclude food stamps) for Adult Household Member:
Alimony for Applicant:
Alimony for Adult Household Member:
Child Support for Applicant:
Child Support for Adult Household Member:
Interest/Dividends for Applicant:
Interest/Dividends for Adult Household Member:
Income from Rent Property for Applicant:
Income from Rent Property for Adult Household Member:
Other Income for Applicant:
Other Income for Adult Household Member:
Military Pay/Allowances (except for Hostile Fire) for Applicant:
Military Pay/Allowances (except for Hostile Fire) for Adult Household Member:
Earned Income Tax Credit (over tax liability) for Applicant:
Earned Income Tax Credit (over tax liability) for Adult Household Member:
Residency Certification*
I, the Applicant, hereby certify that I am a legal resident of the following city/county. I have attached documentation of residency.
City:*
County:*
Certification*
By signing below, I, the Applicant, certify and acknowledge that the information provided here will be used to determine my eligibility, and is true and correct to the best of my knowledge. I understand that this information is subject to verification, and falsification of this information may be grounds for termination from the program and result in prosecution under federal and state laws.
E-Signature of Applicant (please type your name in the box below):*
Date:*
MM slash DD slash YYYY
Reviewed by: (to be completed by Caseworker AFTER SUBMISSION)
Signature of Caseworker:
Date:
MM slash DD slash YYYY

Income/Residency Certification

City of Dallas ESG Program: Income/Residency Certification

Indicate the amount and frequency of each payment below:

Reviewed by: (to be completed by Caseworker AFTER SUBMISSION)