Financial Zero Income Checklist

FINANCIAL ZERO INCOME CHECKLIST

Purpose: This Checklist documents the absence of earned or unearned income for the individual named below for the period specified and identifies supporting documentation provided. Complete all applicable fields, sign the certification, and attach required supporting documents. False statements or omissions may result in repayment obligations, administrative sanctions, or civil/criminal penalties.

Client Information

Period Covered

Start Date:    End Date:

Household Composition

Income Sources — Indicate any income received during the period

Employment (wages, salary) — Amount:

Self-employment / Contract work — Amount:

Unemployment insurance — Amount:

Social Security / Disability benefits — Amount:

Pension / Retirement — Amount:

Child support / Alimony — Amount:

Rental income — Amount:

Investment dividends / interest — Amount:

Other income (describe): Amount:

If no income from any source during the period, check here:

Assets and Resources

Bank accounts (combined balance at end of period):

Cash on hand:

Vehicles (list make/model/year and equity):

Real property interests:

Investments (stocks, bonds):

Supporting Documentation Provided

Bank statements (last 3 months)

Written denial or termination notices for public benefits

Signed affidavit of zero income

Pay stubs / employer statements (if any)

Other documents (describe below)

Declaration and Certification

I, the undersigned, declare under penalty of perjury under the laws of the applicable jurisdiction that the information provided in this Checklist and any attached documentation is true, correct, and complete to the best of my knowledge. I understand that knowingly providing false information or omitting material facts may subject me to administrative remedies, civil liability, and criminal prosecution to the fullest extent permitted by law.

I authorize authorized representatives to verify the information contained in this Checklist, including obtaining records from employers, financial institutions, and benefit providers as necessary to confirm my income and resources. I understand that verification may include obtaining and reviewing bank statements, payroll records, and other financial documents.

If verification reveals income or resources inconsistent with this declaration, I agree that appropriate corrective action may be taken, including cessation of benefits, recovery of funds, reassessment of eligibility, or referral for enforcement action.

Assistance with Completion

Was assistance provided to complete this Checklist?   Yes    No

Acknowledgment

By signing below I acknowledge that I have read and understand the Certification and declarations above. I acknowledge I have supplied truthful information and the supporting documentation listed with this Checklist.

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