All adult household members reporting zero income must complete this form on a quarterly basis
Please answer the following questions honestly and completely.
Food Expenses
If someone other than a household member gives you cash for the groceries, who is it?
Cleaning, Grooming And Paper Product Expenses
If someone other than a household member providing paper products to your family, who is it?
If someone other than a family member of the household provides grooming products, who is it?
If someone other than a member of the household provides cleaning products, who is it?
Transportation Expenses
If someone other than a member of the household makes the car payment, who is it?
If someone other than a member of the household contributes to the car's operating cost, who is it?
Entertainment Expenses
If someone other than a member of your household pays for the cost of your cable TV/satellite service, who is it?
If someone other than a member of your household contributes to the cost of other entertainment, who is it?
Clothing Expenses
If someone other than a member of the household contributes to the cost of clothing, who is it?
Smoking Expenses
If someone other than a member of the household contributes to the cost of smoking, who is it?
Communication Expenses
Does your family have any special telephone services? For example, call waiting, call forwarding, caller ID, etc.
If someone other than a member of the household contributes to the cost of telephone service, who is it?
If someone other than a member of the household contributes to the cost of internet connection, who is it?
Housing And Utility Expenses
If someone other than a member of the household makes a contribution toward housing and utility costs, who is it?
Miscellaneous Expenses
Zero Income Verification
I do hereby swear and attest that I currently have zero income and all the information provided on this form is true and correct. I understand that I am obligated to complete this form on a quarterly basis for as long as I do not have income and it is my responsibility to request this form from the Paragould Housing Authority. I also understand that all changes in my income and the income of any member of the household must be reported to the Poinsett County Housing Authority in writing within ten(10) days of a change. I must complete the Zero Income Form and provide documentation of all changes in income. I also acknowledge that the Poinsett County Housing Authority will contact the Department of Labor and Employment to verify my unemployment. Also, any addresses and phone numbers I provide on this document I give my permission for Release of Information to that individual(s).
WARNING: TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES.
