HomeMy WebLinkAboutcertification-of-no-incomeSelf-Certification of No Income
Instructions: This form intended to be used when an individual applying for subsidized housing lacks income. It is
recommended that income be certified quarterly to account for any changes.
Client Section:
I certify that I (Client’s Name) do not
currently have any income of any type, including (but not limited to):
• Employment income, including part-time or seasonable work;
• Unemployment benefits;
• Social Security Insurance (SSI)/Social Security Disability Insurance (SSDI);
• General Assistance;
• CalWORKS/TANF;
• Child support;
• Alimony; or
• Other sources of regular (not one-time) income.
I certify that the above information is correct.
Signature of Client: Date of Signature:
Staff Section: DO NOT SKIP THIS STEP
If applicable, please add any information below about the client’s income status, including any attempts to confirm the
statement above.
I reviewed the above statement with the client, and confirm the accuracy of the statement to the best of my ability.
Name of Staff (Print):
Staff Member Organization and Title: Staff Phone Number:
Signature of Staff: Date of Signature: