FTH-05 Zero Income Certification (English)


Form 5 of 8

Urban League of Philadelphia ZERO INCOME CERTIFICATION for Adults (18yrs & Over) in the Family This Certification of Zero Income should be completed by an adult family member only (if appropriate). This form is valid for twelve (12) months from the date signed. I, , hereby certify as follow: 1. I am years old. 2. Please read the two options below carefully, check the appropriate box, and sign the form below.


OR

Please see details below.
I hereby certify that I do not individually receive income from any of the following sources:
  • Wages from employment (including commissions, tips, bonuses, fees, etc.).
  • Income from operation of a business.
  • Rental income from real or personal property.
  • Interest or dividends from assets.
  • Social Security payments.
  • Supplemental Security Income Payments (SSI).
  • Social Security Disability Income (SSDI).
  • Payments from annuities, insurance policies, retirement funds, pensions, or death benefits.
  • Unemployment Insurance or disability payments.
  • Public assistance payments.
  • Temporary Assistance for Needy Families (TANF).
  • Periodic allowances such as alimony, child support, or gifts received from persons not living in my household.
  • Sales from self-employed resources (Avon, Mary Kay, EBay, etc.).
  • Any other source not named above.
3. I currently have no income of any kind and there is no imminent change expected in my financial or employment status. The answers to the questions listed above are true and correct to the best of my knowledge. I realize that if these statements are discovered to be false, I may be terminated from this housing counseling program.

Leave this empty:

Signature arrow sign here


Signature Certificate
Document name: FTH-05 Zero Income Certification (English)
lock iconUnique Document ID: e12a6e1c8b0ec7cdaa0c79daeee8ab7ed18b3d4f
Timestamp Audit
May 15, 2019 10:01 pm EDTFTH-05 Zero Income Certification (English) Uploaded by David Bruggink - david.bruggink@gmail.com IP 108.16.112.154
July 3, 2019 10:07 pm EDTDeserie Hill - dhill@urbanleaguephila.org added by - as a CC'd Recipient Ip: 192.168.95.1, 172.17.0.1
July 5, 2019 10:09 pm EDTULP Housing - housing@urbanleaguephila.org added by - as a CC'd Recipient Ip: 192.168.95.1, 172.17.0.1
July 6, 2019 12:39 pm EDTULP Housing - housing@urbanleaguephila.org added by - as a CC'd Recipient Ip: 192.168.95.1, 172.17.0.1
July 6, 2019 10:18 pm EDTULP Housing - housing@urbanleaguephila.org added by - as a CC'd Recipient Ip: 192.168.95.1, 172.17.0.1