Zero Income Statement

You should only complete this form if you have been contacted by your certification specialist and asked to do so and someone in your household currently has no income. If you are receiving an error when trying to submit your form, try a different browser (Google Chrome, Firefox, etc.) or using a different computer/device.

Was this form requested from you by AMHA staff?*

If NO, please stop and do not complete this form until it is requested by an AMHA staff person.

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Program Type*

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HCVP Certification Specialist*

Please select the HCVP employee that contacted you to complete this online form. If you are not on this program type, select "Not on this program."

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LHA/Multi-Family Certification Specialist*

Please select the LHA/Multi-Family employee that contacted you to complete this online form. If you are not on this program type, select "Not on this program."

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Public Housing Development Name*

Please select the development in which you live. If you are not on this program type, select "None of the properties listed."

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Head of Household Last 4 SSN*

Head of Household First Name*

Head of Household Last Name*

Zero Income Member*

First and Last Name of person in household reporting zero income.

Phone*

How much does the zero income person spend PER MONTH on: phone, cleaning products, personal care, gas, bus passes, loans, credit card payments, and cable/internet?*

Type in $ per month.

How do they plan to pay for these expenses in the future?*

Name, Address, and Phone Number of who you anticipate will pay for these items:*

What is the reason you have zero income (lost employment, unpaid leave etc.). Please explain:*

Have your expenses been the same over the last 12 months (or the months listed on your appointment letter)?*

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If No, which months were different and what was the amount?*

Will these contributions continue longer than the next 12 months?*

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Participant Certifications

Please review each statement and choose "Yes" that you have read and understand the statement. If you have any questions regarding the certifications, please contact your certification specialist.

I certify that I have NO income. I understand that I am required to report within 10 days, in writing, any changes in income and household composition. Failure to report this information may result in owing AMHA back rent and/or the termination of my subsidy.*

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I/We certify that the above information given to the Akron Metropolitan Housing Authority on household composition, income, net family assets, allowances and deductions is accurate and complete to the best of my/our knowledge and belief. I /We understand that giving false statements or information can be grounds for punishment under federal and state laws. I/We also understand that giving false statements or information can be grounds for termination of housing assistance. I understand that if my actual earnings exceed the anticipated income that I may be required to report the changes to the Housing Authority.*

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Electronic Signature - Type your FULL NAME*

MUST be for the person reporting zero income.

Please review the Electronic Signature line above. Does your FULL NAME show?*

If no, please re-type your name on the Electronic Signature line.

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