Statement of No Income

To be completed by household members age 18 and over

Property Name: _____________________________________________________________________

Tenant Name: ______________________________________________ Unit #: ________________

I, ________________________________, do hereby certify that I do not individually receive income from any of
the following sources:

a. Wages from employment (including commissions, tips, bonuses, fees, etc.);

b. Operation of a business;
c. Rental income from real or personal property;
d. Interest or dividends from assets;
e. Social Security benefits;
f. Annuities, insurance policies, retirement funds, pensions or death benefits;
g. Public assistance payments;
h. Payments for alimony, child support or gifts received from persons not living in the household;
i. Unemployment or disability payments;
j. Sales from self-employed resources (Avon, Mary Kay, eBay, etc.);
k. Any other source not mentioned above.

I certify that I currently have no income of any kind and that, if there is any change in my financial or income
status, I will report it immediately to management.

____________________________________________________ _______________________
Signature of Applicant/Tenant Date

Under penalty of perjury, I certify that the information presented in this certification statement is true and accurate to the best of my
knowledge. The undersigned further understands that providing false representations herein constitutes an act of fraud. False, misleading
or incomplete information may result in the termination of subsidy and the lease agreement.

Section 8 12/2014