LIHEAP Zero Income Statement Form

LIHEAP Zero Income Statement Form

ZERO INCOME STATEMENT

Income is understood to include but is not limited to the following: Wages from an employer, unemployment insurance, time loss for work related injuries, child support received, military or other pension payments, social security, supplemental security income, TANF, work study programs, money received through self-employment, or odd jobs in exchange for food, shelter, or utilities.
Full Name(Required)
I herby declare that I have receive no income for the following months, select the three full months before the month in which you summited your application.
Select the months you had zero income(Required)
Select all much in which you had zero income
If a friend or relative is helping pay your bills, please list name(s) and phone number(s)

During the 3 months listed above, did anyone in your household have sources of income you DID NOT think to report?(Required)
If you mark any of the boxes below, you have received income/assistance and will need to provide proof.

I authorize LEKT LIHEAP program to verify information offered on this Zero Income form.

Clear Signature
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