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Outstate Missouri

Certification of Zero Income Self Affidavit

Certification of Zero Income Self Affidavit

To be completed by an adult head of household member, who is claiming "Zero Income" from any source. ONLY FILL OUT IF YOU HAVE ZERO INCOME!
Name
Address
I hereby certify that I do not individually receive income from any of the following sources:
a. Wages from employment (including commissions, tips, bonuses, fees, ect.);
b. Income from operation of a business;
c. Rental income from real or personal property;
d. Interest or dividends from assets;
e. Social Security payments, annuities, insurance policies, retirement funds, pensions, or death benefits;
f. Unemployment or disability payments;
g. Public assistance payments;
h. Periodic allowance such as alimony, child support, or gifts received from person not living in my household;
i. Sales from self-employed resources (Avon, Mary Kay, Shaklee, etc.);
j. Any other source not named above.
Choose one:
Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. The undersigned further understand(s) that providing false representation herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination or repayment of the Heat-Up St. Louis inc. pledge.
Name
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