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Household Name: <br />Development Name: <br />CERTIFICATION OF ZERO INCOME <br />(To be completed by Ad& housdrold members only, if apprapciate.) <br />Unit # (if assigned): <br />City: <br />200512606 <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 firm real or personal property, <br />d. Interest or dividends from assets; <br />C. 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 received from persons not living in my <br />household; <br />i. Sales from self - employed resources (Avon, Mary Kay, Shaklec, 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. l 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 of my <br />lmowledge. The undersigned fitrther understand(s) that providing false representations herein constitutes an act of fraud. <br />False, misleading or incomplete information may result in the termination of a lease agreement. <br />Signature of Applicant/Tenant Pr nted Name of ApplicanuTenant <br />Date <br />