HCV Zero Income Status Packet

Step 1 of 4

This form is to be completed and submitted if you are claiming Zero Income Status.

Failure to declare income or income source will result in termination of assistance.

Failure to declare an expense generated by the household will result in termination of assistance.

Falsifying, altering, or omitting any information or documentation will result in termination of assistance.

All questions must be answered.

If you or anyone in your family is a person with disabilities, and you require a specific accommodation to fully utilize our programs and services, please contact the housing authority.

Title 18, Section 1001 of the U.S. Code, states that a person who knowingly and willingly makes false or fraudulent statements to any Department or Agency of the U.S. or the Department of Housing and Urban Development is guilty of a felony and subject to jail, fees, and fines.

Name(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

INCOME STATEMENT
You must list all sources of income. Anything of value that benefits household members must be declared. Income includes all wages, grants, gifts, loans, donations, etc.

Does any member of the household have any of the following income?
Wages from employment?(Required)

Yes

No
Child Support?(Required)

Yes

No
Child Support (Including Private Pay)?(Required)

Yes

No
TANF?(Required)

Yes

No
Pension?(Required)

Yes

No
SS or SSI?(Required)

Yes

No
Township?(Required)

Yes

No
Social Services?(Required)

Yes

No
Other Disability Payments?(Required)

Yes

No
Babysitting?(Required)

Yes

No
Handyman/Lawn Care/Snow Removal?(Required)

Yes

No
Cleaning?(Required)

Yes

No
In home party sales (Tupperware, Mary Kay, etc.)?(Required)

Yes

No
In home hair styling, braiding or nail services?(Required)

Yes

No
Cash Jobs?(Required)

Yes

No
Other Income?(Required)

Yes

No
Non-Monetary gifts (car, food, clothes, etc.)?(Required)

Yes

No

You may be required to provide receipts or other documentation for expenses, including utility bills, rent or housing costs, medical, etc. Failure to provide required documents or to provide consent may result in the denial or termination of assistance.

I understand that any misrepresentation of information or failure to disclose information requested on this application may disqualify me from consideration for admission or participation to any housing assistance program.

Notice: Any attempt to obtain Public Housing, any rent subsidy or rent reduction by false information, impersonation, failure to disclose or other fraud, and any act or assistance to such attempt is a crime.
Digital Signature:(Required)
Date(Required)
MM slash DD slash YYYY

Please provide names and addresses of any family members/friends listed above who assist you with your expenses:
Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code

Phone
Email

Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code

Phone
Email

Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code

Phone
Email

Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code

Phone
Email

Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code

Phone
Email

HCV Zero Income Status Packet

HCV Zero Income Status Packet

Zero Income Checklist and Worksheet

FOOD EXPENSES

HOUSEHOLD GOODS: Cleaning, Grooming and Paper Products

CLOTHING EXPENSE

SHELTER EXPENSE: Housing and Utilities

TRANSPORTATION EXPENSE

RENTAL FURNITURE, APPLIANCE OR OTHER RENTAL ITEM EXPENSE

COMMUNICATION EXPENSES

ENTERTAINMENT EXPENSES

SMOKING/TOBACCO EXPENSES

CREDIT CARD EXPENSE

MISCELLANEOUS EXPENSES

INCOME STATEMENT