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201109462 <br /> CERTIFICATION OF ZERO INCOME <br /> (To be completed by household members age 18 and over,if appropriate.) <br /> Household Name: Unit#(if assigned): <br /> Development Name: City: <br /> (This form does not need to be completed, if an Unemployed Affidavit has been completed) <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 /> £ 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, Shaklee, etc.); <br /> j. Financial Aid(scholarships, grants,other contributions, etc); <br /> k. 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 of my <br /> knowledge. The undersigned further 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 Printed Name of Applicant/Tenant Date <br /> (Updated 12/10) <br />