This form must be completed and signed by the applicant whose household has little or no income. Has your household received any income in the month before you applied for …

sted, a signed Self-Declaration of Zero Income is permissible to use. The Applicant must fill out and sign the Self-Declaration of Zero Income form listing all household members declaring …

Grantees often encounter applicants or household members claiming to have no income. In those cases, they will interview the applicant or household member and / or have them fill out a form …

NOTE: THIS FORM SHOULD BE COMPLETED FOR ALL ADULT HOUSEHOLD MEMBERS 18 YEARS OF AGE OR OLDER WHO REPORT ZERO INCOME.

NO INCOME (ZERO INCOME) STATEMENT Each adult (ages 18+) household member reporting no income (zero income) is required to complete this statement form.

Completed by all household members 18 and over without income. Completed by the person who contributes to zero income household to cover household expenses.

To the Individual: Complete this form if you can certify the individual's income situation. Warning: Any person who aids another person in obtaining assistance (or benefits) fraudulently is …

Jan 1, 2022 · LIHEAP ZERO INCOME STATEMENT FORM I, (Full Name) (SSN) do hereby certify that I am unemployed and have no income for the following reason: (check appropriate …

Age ________, Date of Birth ____________________ certify that I am a member of the above household which applied for USF/LIHEAP benefits, and at the present time do not have any …

EXHIBIT 1.1.1 (D) DECLARATION OF NO INCOME I ____________________________________, do hereby declare that I have not (Applicant …