* 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.
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.
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.