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NO INCOME DECLARATION

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Please note for household member(s) 18 years or older who are declaring no income. Clearly type Full Names & Social Security Number(s)!

I, hereby declare that I/We have not Received any income for the last three (3) month(s) of:

 

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The reason that  I/WE have had no income for the months listed above is as follows:

 

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I/We declare by checking this statement that the information provided on this form is true and correct to the best of my/our knowledge.  I understand that because The PL102-477 Program(s) are federally funded and the penalty for providing false information shall not be more than $10,000 dollars and/or not more than five (5) years imprisonment.

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