CERTIFICATION OF ZERO INCOME

(To be completed by an adult household member if appropriate)

Head of Household Name: Unit No.:

Development Name and Address:

A. Within the next 12 months, will you receive income from any of the following sources?

You must supply additional information to verify all ‘Yes’ answers.

Y/N

Wages, bonus, commissions, tips, etc.

Y/N

Self-employment (Uber/Lyft, online sales, etc.)

Y/N

Unemployment Benefits

Y/N

Annuities, insurance policies, stocks, etc.

Y/N

Worker’s Compensation

Y/N

Pensions, IRA, 401K

Y/N

Disability Payments

Y/N

Income from rental property

Y/N

Alimony

Y/N

Death Benefits

Y/N

Child Support

Y/N

Interest/dividends from assets, including bank accounts

Y/N

Social Security

Y/N

Sales from Mary Kay, Tupperware, Pampered Chef, etc.

Y/N

Help with paying bills or other expenses

or regular gifts of money from family or

friends who don’t live with you

(including online donations such as

GoFundMe or through a local bank)

Y/N

Work for cash (babysitting, lawncare, etc.)

Any other source (if yes, explain below) e.g. TANF/Public

and/or General Assistance

Mark the ONE statement that applies to you:

I do not expect to have any source of income in the next 12 months.

I have been hired for a new job or I will be receiving another source of income soon. I will give you more information

for verification purposes.

C. If you have circled N for each source of income in section A, and you do not expect to have any

source of income in the next 12 months, explain how you will pay for the following:

(write N/A if not applicable):

Rent (including garage rent, if applicable)

Utilities

Food

Family clothing

Children’s school supplies

Cell phone or phone

TV (cable, dish, satellite) and/or internet

Medical care

Medications & prescriptions:

Personal care products (shampoo, toothpaste, etc.)

Vehicle expenses (car payments, insurance, fuel, etc.)

Payments on credit card balances

Other expenses not listed above

Additional comments

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 constitutes an act of fraud. False, misleading, or incomplete information may

result in the termination of my lease agreement. I understand that I may be required to periodically update this information as

requested by owner/agent.

Signature of Applicant/Tenant Printed Name of Applicant/Tenant Date

PENALTIES FOR MISUSING THIS CONTENT: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly

making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be

subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this

verification form is restricted to the purposes cited above. Any person who knowingly or willingly requests, obtains, or discloses any information under false pretenses

concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure

of information may bring civil action for damages and seek other relief, as may be appropriate, against the officer or employee of HUD or the owner responsible for the

unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7), and

(8). Violations of these provisions are cited as violations of 42 USC 408 (a), (6), (7), and (8).

Certification of Zero Income (2019)

Exhibit C4