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    Zero Income Claimant Affidavit

    Uploaded by

    Hazel-mae Labrada
    This document is an affidavit for someone claiming zero income over the past 12 months. It requires the signee to certify that they have not received any income, do not have proof of income, and that the information provided is true. It also allows state and federal agencies to verify tax information. The signee must then provide details on how their living expenses have been met over the past year through housing, utility, food, or other assistance.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Zero Income Claimant Affidavit

    Uploaded by

    Hazel-mae Labrada
    225 views1 page
    This document is an affidavit for someone claiming zero income over the past 12 months. It requires the signee to certify that they have not received any income, do not have proof of income, and that the information provided is true. It also allows state and federal agencies to verify tax information. The signee must then provide details on how their living expenses have been met over the past year through housing, utility, food, or other assistance.

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    Zero Income Claimant Affidavit

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    This document is an affidavit for someone claiming zero income over the past 12 months. It requires the signee to certify that they have not received any income, do not have proof of income, and that the information provided is true. It also allows state and federal agencies to verify tax information. The signee must then provide details on how their living expenses have been met over the past year through housing, utility, food, or other assistance.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    225 views1 page

    Zero Income Claimant Affidavit

    Uploaded by

    Hazel-mae Labrada
    This document is an affidavit for someone claiming zero income over the past 12 months. It requires the signee to certify that they have not received any income, do not have proof of income, and that the information provided is true. It also allows state and federal agencies to verify tax information. The signee must then provide details on how their living expenses have been met over the past year through housing, utility, food, or other assistance.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Zero Income Affidavit

    I, _____________________________________, hereby certify under the penalties of perjury and fraud the following: (1)
    I have not received any income1in the past twelve (12) months prior to this date; (2) I do not have any additional proof
    of income; and (3) the information that I have provided in this affidavit is true and accurate. In addition, I authorize
    state and federal agencies to verify any of this information and hereby consent to the release of my West Virginia Tax
    Return for this purpose. My household living expenses have been met over the past twelve (12) months as follows:

    Housing Assistance: _______________________________________ Date Received: _____________


    Source of Assistance/Name: _____________________________________________________________
    _____________________________________________________________________________________

    Utility Assistance: _________________________________________ Date Received: _____________


    Source of Assistance/Name: _____________________________________________________________
    _____________________________________________________________________________________

    Food Assistance: _________________________________________ Date Received: _____________


    Source of Assistance/Name: _____________________________________________________________
    _____________________________________________________________________________________

    Cash or Other Assistance: __________________________________ Date Received: _____________


    Source of Assistance/Name: _____________________________________________________________
    _____________________________________________________________________________________

    I acknowledge that 18 U.S.C. 1001, Fraud and False Statements, provides among other things, in any matter within the
    jurisdiction of the executive, legislative, or judicial branch of the Government of the United States, anyone who knowingly and
    willfully: (1) falsifies, conceals, or covers up by any trick, scheme, or device a material fact; (2) makes any materially false, fictitious,
    or fraudulent statement or representation; or (3) makes or uses any false writing or document knowing the same to contain any
    materially false, fictitious, or fraudulent statement or entry; shall be fined under this title, and/or imprisoned for not longer than five
    (5) years.

    __________________________________________________ Date: ______________


    Signature of Zero Income Claimant
    NOTARY ACKNOWLEDGEMENT

    WITNESS my hand and seal this ______ day of ______________ 20___.

    My County of Residence: ________________ ____________________________________


    Notary Public -Signature

    My Commission Expires: ________________ ____________________________________


    Notary Public -Printed Name

    HEAD OF HOUSEHOLD AND AGENCY SIGNATURES

    ______________________________________________________ Date: _______________________________


    Head of Household Signature

    ______________________________________________________ Date: _________________________


    Agency Representative Signature

    1
    Income means Cash Receipts earned and/or received by the applicant before taxes during applicable tax year(s). Cash Receipts include the
    following: money, wages and salaries before any deductions; net receipts from non-farm self-employment (receipts from a persons own business
    or from an owned or rented farm after deductions for business or farm expenses); regular payments from social security, railroad retirement,
    unemployment compensation, strike benefits from union funds, workers compensation, veterans payments, training stipends, alimony, and
    military family allotments; private pensions, government employee pensions (including military retirement pay), and regular insurance or annuity
    payments; dividends and/or interest; net rental income and net royalties; periodic receipts from estates or trusts; and net gambling or lottery
    winnings. V.11.2013

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