Certification of Zero Income

Texas Department of Housing & Community Affairs: Certification of Zero Income
A “Certification of Zero Income” should be completed by adult household members only (if appropriate). If there are any sources of income listed that you (the applicant) need clarification on, please contact the Contract Administrator, Owner or Management Office Personnel.
To be completed by administrator/owner/management AFTER SUBMISSION:
The applicant may skip this section and proceed to the "To be completed by applicant/resident" section.
Administrator/Owner/Management Name:
Contact Name:
First Last
Administrator/Owner/Management Address:
Street Address Address Line 2 City State ZIP Code
Administrator/Owner/Management Email:
TDHCA Number:
Contact Title:
Administrator/Owner/Management Phone:
Administrator/Owner/Management Fax:
To be completed by applicant/resident:
Applicant/Resident Name:*
First Last
Applicant/Resident Email:
Certification Part I*
I hereby certify that:
I do not individually receive income from any of the following sources:
•Wages from employment (including commissions, tips, bonuses, fees, etc.);
•Income from operation of a business;
•Rental income from real or personal property;
•Interest or dividends from assets;
•Social Security payments;
•Supplemental Security Income payments;
•Payments from annuities, insurance policies, retirement funds, pensions, or death benefits;
•Unemployment or disability payments;
•Public assistance payments (other than food stamps);
•Periodic allowances from alimony or child support;
•Gifts received from persons not comprising the household;
•Sales from self-employed resources (Avon, Mary Kay, Pampered Chef, Shaklee, etc.);
•Any other source not named above; AND
Certification Part II*
I hereby certify that:
I currently do not have income of any kind and there is no imminent change expected in my financial oremployment status during the next 12 months; AND
I will be using the following sources of funds to pay for rent, utilities, and/or other necessities:*
Applicant Certification
Under penalty of perjury, I certify, to the best of my knowledge, that the information presented in this certification is true and accurate. The undersigned further understands that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination of participation under a Texas Department of Housing and Community Affair’s (THDCA) Affordable Housing Program
Household/Resident E-Signature (please type your name in the box below):*
Date:*
MM slash DD slash YYYY
City of Dallas ESG Program: Declaration of No Income Statement
Applicant/Resident Name:*
First Last
I do hereby declare that I have no documented income due to: (choose the best option that applies to your situation)*
- I have not worked and have no source of income.
- I have not worked since ________ and have no source of income.
- I did not work and earned no income during the period of ________ to ________.
Enter last date of work:
Enter time period of no earned income (________ to ________):
I have assistance pending.*
- Yes
- No
If yes, enter income source:
Certification*
I certify that the above information is true and correct to the best of my knowledge and belief. I understand that the information will be verified to the extent possible; and that I may be subject to prosecution for providing false or fraudulent information.
Applicant E-Signature (please type your name in the box below):*
Date:*
MM slash DD slash YYYY
Address:
Street Address Address Line 2 City State ZIP Code
Caseworker will provide signature AFTER SUBMISSION
Caseworker Signature:
Date:
MM slash DD slash YYYY
ESG Self-Declaration of No Income
ESG Applicant Name:*
First Last
Adults Households Family Members: (list all with no income)*
Certification Part I
This is to certify the income status for the above named individuals. Income includes but is not limited to:
• The full amount of gross income earned before taxes and deductions.
• The net income earned from the operation of a business, i.e., total revenue minus business operating expenses. This also includes any withdrawals of cash from the business or profession for your personal use.
• Monthly interest and dividend income credited to an applicant’s bank account and available for use.
• The monthly payment amount received from Social Security, annuities, retirement funds, pensions, disability and other similar types of periodic payments.
• Any monthly payments in lieu of earnings, such as unemployment, disability compensation, SSI, SSDI, and workers compensation.
• Monthly income horn government agencies excluding amounts designated for shelter and utilities, WIC, food, stamps, and childcare.
• Alimony, child support and foster care payments received from organizations or from persons not residing in the dwelling.
• All basic pay, special clay and allowances of a member of the Armed Forces excluding special pay for exposure to hostile fire.
Certification Part II*
I certify, under penalty of perjury, that the individuals listed above do not have any income from any source at this time and that I will inform my case manager of any changes in income for the household while my household is enrolled in ESG.
ESG Applicant E-Signature (please type your name in the box below):*
Date:*
MM slash DD slash YYYY
ESG Staff Verification - COMPLETED BY STAFF AFTER SUBMISSION
I understand that third-party verification is the preferred method of certifying income for ESG assistance. I understand self-declaration is only permitted when I have attempted to but cannot obtain third party verification.
Documentation of attempt made for third party verification:
ESG Staff Signature:
Date:
MM slash DD slash YYYY