Weatherization Manual Policies and Procedures Supporting Documents for United States Department of Energy (doe) United States Department of Health and Human Services (hhs) Bonneville Power Administration



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( Y N ) Date: Reviewer:



  • * If client has more than six children please use back of this form.

  • Total gross income: = the household’s average monthly income.

  • Number of months documented:

  • I certify that the above information I have provided is a complete and accurate list of all household members and their income for the period, and ________. I understand that I am signing this form under penalty of criminal prosecution if I knowingly give false information resulting in payment to which I am not entitled.





  • Applicant’s Signature Date

  • Declaration of No Income

  • I, , do hereby declare that I have not received any income for the month(s) of:

  • 1. 2. 3.

  • The reason that I have had no income for the months listed above is as follows:







  • I have been meeting my basic living needs for food, shelter and utilities in the following way:

  • Food:

  • Shelter:

  • Utilities:

  • I certify that the information contained above is complete and accurate to the best of my knowledge. I understand that I am signing this statement under penalty of prosecution if I knowingly give false information, which results in assistance received for which I am not eligible.



  • Client Signature/Date Agency Representative/Date

  • State of Washington



  • County of _______________



  • I certify that I know or have satisfactory evidence that (name of person) is the person who appeared before me, and said person acknowledged that (he/she) signed this instrument and acknowledged it to be (his/her) free and voluntary act for the uses and purposes mentioned in the instrument.



    1. Dated: ______________

    1. _______________________



    1. (Signature)

    1. (Seal or stamp)





    1. _______________________



    1. Title



    1. My appointment expires: ________________


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