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Declaration of Household Income

Instructions: This form is to be completed by the person applying for assistance if any of the following situations apply to the applicant and/or any household member age 18 and over for the previous month: • Had no income and verification cannot be obtained from a governmental entity such as the Department of Human Resources, Department of Labor, Public Housing manager, etc. • Received income from occasional work such as lawn care, house cleaning, babysitting, car repair, etc. when a receipt book is not maintained. • Received money from family/friends. (This includes funds for rent, food, utilities, and other needs.) • Received income not reported elsewhere.

Applicant’s name (please print):

Applicant’s address (please print):

Did you or any household member age 18 and over have no income last month? If so, complete the following for you and every adult: Name How long has this person had no income?

Did you or any household member age 18 and over receive income from occasional work when a receipt book was not maintained, receive money from family or friends, or receive any income not reported elsewhere last month? If so, complete the following for you and every adult:

Name Amount Source of income

How do you pay your rent/mortgage?

How do you pay for food?

How do you pay for your utilities?

I certify that the information provided above is true and complete to the best of my knowledge. I understand I may be required to provide proof of any information given and that providing false information will invalidate this form and may require the repayment of any assistance received based on the false information. I understand that I am subject to all applicable Federal or State laws concerning fraud.

Applicant’s Signature:

Date:

LIHEAP-102 Reviewed 2024