Name	     	
Social Security Number	     	

I hereby certify that I do not receive income from any of the following sources:

1.	Wages from employment (including commissions and fees).
2.	Income from operation of a business.
3.	Rental income from real or personal property.
4.	Interest or dividends from assets.
5.	Social Security payments, annuities, insurance policies, retirement funds, pensions, disability or death benefits.
6.	Unemployment or disability payments.
7.	Public assistance payments.
8.	Alimony or child support.
9.	Monetary contributions or gifts regularly received from persons not living in the unit (including rent or utility payments regularly paid on my behalf).
10.	Educational grants and/or scholarships or Veterans Administration benefits available for subsistence after deducting expenses for tuition, fees and books.
11.	Sales from self-employed resources (Avon, Mary Kay, etc.).

and, that I have no income of any kind whatsoever at this point in time and do not anticipate income from any of the above sources within the next thirty (30) days or less depending upon the projected period of -0- income.

I understand that I must re-verify this information every thirty (30) days or less depending upon the projected period of -0- income. Further, should I find employment or begin to receive assistance or begin to receive income from any of the sources listed above, I will report the income immediately.

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	Signature	
		
	Date	

WARNING: Section 1001 of Title 18 of the U. S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the United States as to any matter within its jurisdiction.