CERTIFICATION OF ZERO INCOME
(To be completed by adult (18 years or older) household members only, if appropriate)
I certify that I do not individually receive income or have not received income from any of the
following sources for the period _________________ through __________________
a. Wages from employment (including commissions, tips, bonuses, fees, etc)
b. Income from operation of a business
c. Rental income from real or personal property
d. Interest or dividends from assets
e. Unemployment or disability payments
f. Public assistance payments
g. Periodic allowances such as alimony, child support, or gifts received from persons not living
in my household
h. i. Sales from self-employed resources (Avon, Mary Kay, Amway, etc…)
Social Security payments, annuities, insurance policies, retirement funds, pensions, or death
benefits
j. Veteran’s Benefits
k. Supplemental Security Income
l. Any other source not named above
I currently have no income of any kind and there is no imminent change expected in my financial
status or employment status during the next 12 months.
Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. I further understand that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in the loss of the AHP subsidy.
