MOR-05 Zero Income Certification (English)

Form 5 of 9

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. 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: MOR-05 Zero Income Certification (English)
lock iconUnique Document ID: 00b57f4ab717f5d43186f33e2ec8d595d5a464de
Timestamp Audit
May 15, 2019 10:01 pm EDTMOR-05 Zero Income Certification (English) Uploaded by David Bruggink - IP,
July 3, 2019 10:06 pm EDTDeserie Hill - added by - as a CC'd Recipient Ip:,
July 5, 2019 10:09 pm EDTULP Housing - added by - as a CC'd Recipient Ip:,
July 6, 2019 12:39 pm EDTULP Housing - added by - as a CC'd Recipient Ip:,
July 6, 2019 10:18 pm EDTULP Housing - added by - as a CC'd Recipient Ip:,