Zero Income Form
Client Name (Print) ____________________________________________________
Address: ________________________________________________________
__________________________________________ _________________ _____________________
(City)
(State)
(Zip code)
This is a statement certifying that you have no income whatsoever from any source.
This statement is made to establish eligibility to receive services and to qualify for certain
programs. Your signature below makes this a legal declaration. If false, you may be
denied services in future and be legally required to repay any financial assistance.
I certify that I have no income from any source. I am currently NOT working, have no
assets, are not receiving grants or government assistance of any kind, and are not receiving
financial assistance from any church, non-profit organization, family member or friend.
I plan to pay the following expenses as stated below with/by:
Food:
________________________________________
Shelter/Rent:
________________________________________
Medical:
________________________________________
Other Living Expenses:
________________________________________
I am currently looking for employment:
Yes
No
I certify that the information given above is true and complete to the best of my knowledge. I
understand that providing false or misleading information may make me subject to criminal penalties
and disqualify me for housing services from Utah Community Action Program.
___________________________________
____________________________
Signature
Date
Updated March 2019
03/20/2020