NHE, Inc.
(INSERT PROPERTY NAME)
Resident Name: ______Apartment #:______
ZERO INCOME QUESTIONNAIRE CERTIFICATION
This notice is to verify that I am presently unemployed and have no other source of income. I will report to the office immediately when any changes occur in my employment or income status. I further understand that if I fail to report these changes immediately to the office, and as a result I am charged a rent less than the amount required by HUD Rent Formulas, I agree to reimburse the Management for the difference between the rent I should have paid and the rent I was charged.
YES / NO1. Do you have any other source of income except what you have stated in your application?
If yes, what source?
If yes, how much per month? $
2. Do you get any money from Social Security office?
3. Do you get any money from Human Services (DHS) (AFDC)?
4. Do you get any money from Unemployment office, any other governmental office?
5. Do you get any money from family, friends or charitable entity?
6. Do you get any money from child support?
7. Do you get any money from alimony?
8. Do you have any children over the age of 18 working and living at home?
9. Do any of your children receive money from Social Security?
10. Do you or anyone living with you receive any pension funds?
11. Do you receive any interest on CD’s or savings?
12. Are you paying a rental, lease or purchase payment for rented items (TV, VCR, Furniture, etc.)?
If so, how much per month? $
13. Do you drive a car which will be kept on the property? ______If yes, do you make payments?
14. Do you make any other payments not covered above to any finance agency, credit card company or other entity?
15. Do you have a home phone, cell phone or both?
16. Do you have cable TV/Satellite?
IF YOU HAVE NO INCOME FROM THE ABOVE, HOW WILL YOU PAY FOR THE FOLLOWING?
ITEMS / COST PER MONTH / INCOME SOURCEAutomobile(s) / $
Gas for automobile / $
State required automobile insurance / $
Electricity / $
Telephone or cell phone / $
Cable (includes HBO, Cinemax) / $
How do you plan to purchase the following?
Paper products – (toilet paper, paper plates, school supplies, Kleenex, etc.)?
Grooming Aids – (deodorant, toothpaste, soap, dish detergent, shaving cream, etc.)?
Groceries (all other food, etc.)?
I/we certify that these statements are true to the best of my/our knowledge and belief. I/we understand that I/we can be fined up to $10,000 or imprisoned up to five years or have my/our lease at the above named property terminated if I/we furnish any false or incomplete or misleading information on this form.
I/we certify that I/we receive $ per month to help pay the above bills.
Applicant/Resident: Date:
Applicant/Resident: Date:
PENALTIES: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willingly requests, obtains, or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages and seek other relief, as may be appropriate, against the officer or employee of HUD or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 42 USC 208a (6), (7) and (8). Violations of these provisions are cited as violations of 42 USC 408a (6), (7) and (8).
O - 1 Zero Income Questionnaire 1 of 1 February 2015 REV