ZERO INCOME VERIFICATION

ZERO INCOME VERIFICATION

This Checklist and Worksheet is to be completed for all families whose Total Tenant Payment equals the Minimum Rent, or, for all families reporting less than $250 per month in total income. The form should be completed prior to admission and at recertifications. The family is required to submit documentation of amounts claimed.

SECTION 1: TENANT INFORMATION

Please list the Head of Household information below.
Full Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number

Section II: EXPENSES

Food/Grocery
Do you receive food stamps?

YesNo
What is the monthly amount?
In dollars
Does anyone contribute groceries or meals to you or any of your family members?

YesNo
If so, List who contributes this income, and their address.
Name
Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What is the monthly amount?
In dollars

SECTION II: EXPENSES (cont'd)

Housing/Utilities
Do you subscribe to Cable/Satellite services

YesNo
If so, List who contributes this income, and their address.
Name
Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What is the monthly amount?
In dollars

SECTION II: EXPENSES (cont'd)

Housing/Utilities
Do you subscribe to phone services

YesNo
If so, List who contributes this income, and their address.
Name
Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What is the monthly amount?
In dollars

SECTION II: EXPENSES (cont'd)

Housing/Utilities
List who contributes toward your electric bill and their address.
Name
Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What is the monthly amount?
In dollars

SECTION II: EXPENSES (cont'd)

Automobile
Do you have an automobile?

YesNo
If yes, who contributes toward your automobile expenses?
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What is the monthly amount?
In dollars

SECTION II: EXPENSES (cont'd)

Children
Does anyone help you with clothing expenses?

YesNo
If yes, who contributes toward your clothing expenses?
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What is the monthly amount?
In dollars

SECTION II: EXPENSES (cont'd)

Children
Does anyone help you with school supplies

YesNo
If yes, who contributes toward your school expenses?
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What is the monthly amount?
In dollars

SECTION II: EXPENSES (cont'd)

Health Expenses
Does anyone help you with medical expenses?

YesNo
If yes, who contributes toward your medical expenses?
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What is the monthly amount?
In dollars

SECTION II: EXPENSES (cont'd)

Personal Care
Does anyone help you with personal care expenses? (toilet paper, napkins, feminie products, soap, shampoo etc.)

YesNo
If yes, who contributes toward your personal care expenses?
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What is the monthly amount?
In dollars
Total Monthly Income:

SECTION III: ADDITIONAL INFORMATION
List any additional information below.

SECTION IV: CERTIFICATION AND DISCLOSURE
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, the PHA and any owner (or any employee of HUD, the PHA 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 willfully 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, the PHA 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). Violation of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).
By my signature I certify that the information I have provided above is true and complete. I understand that if I furnish false or incomplete information I can be fined up to $10,000 or imprisoned up to five years, and/or lose the subsidy HUD pays and/or have my rent increased. Any assistance paid in error must be returned to HUD. I also give the Housing Authority of the City of Vidalia permission to verify all the above information and allow them to contact people listed above.
APPLICANT'S SIGNATURE*
Applicant's Initials
Should be Empty: