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EXHIBIT B -3 200109053 <br />CERTIFICATION OF ZERO INCOME <br />(To be completed by adult household members only, if appropriate.) <br />Household Name: Unit No. <br />Development Name: City: <br />1. I hereby certify that I do not individually receive income from any of the following sources: <br />a. Wages from employment (including commissions, tips, bonuses, fees, etc.); <br />b. Income from operation of a business; <br />C. Rental income from real or personal property; <br />d. Interest or dividends from assets; <br />e. Social Security payments, annuities, insurance policies, retirement funds, pensions, or death <br />benefits; <br />f. Unemployment or disability payments; <br />g. Public assistance payments; <br />h. Periodic allowances such as alimony, child support, or gifts from persons not living in my household; <br />i. Sales from self - employed resources (Avon, Mary Kay, Shaklee, etc.); <br />j. any other source not named above. <br />2. I currently have no income of any kind and there is no imminent change expected in my financial status or <br />employment status during the next 12 months. <br />3. I will be using the following sources of funds to pay for rent and other necessities: <br />Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best <br />of my knowledge. The undersigned further understand(s) that providing false representations herein constitutes an <br />act of fraud. False, misleading or incomplete information may result in the termination of a lease agreement. <br />Signature of Applicant/Tenant <br />01- 351904.01 <br />Printed Name of Applicant/Tenant <br />Date <br />