"Certification of Zero Income" - New York

Certification of Zero Income is a legal document that was released by the New York State Homes and Community Renewal - a government authority operating within New York.

Form Details:

  • Released on January 1, 2019;
  • The latest edition currently provided by the New York State Homes and Community Renewal;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the New York State Homes and Community Renewal.

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CERTIFICATION OF ZERO INCOME
(Each adult household member must complete this form.)
Head of Household Name:
Unit No.:
Development Name and Address:
A. Within the next 12 months, will you receive income from any of the following sources?
You must supply additional information to verify all ‘Yes’ answers.
❑Yes ❑No
❑Yes ❑No
Wages, bonus, commissions, tips, etc.
Self-employment (includes Uber/Lyft, online sales, etc.)
❑Yes ❑No
❑Yes ❑No
Unemployment Benefits
Annuities, insurance policies, stocks, etc.
❑Yes ❑No
❑Yes ❑No
Worker’s Compensation
Pensions, IRA, 401K
❑Yes ❑No
❑Yes ❑No
Disability Payments
Income from rental property
❑Yes ❑No
❑Yes ❑No
Alimony
Death Benefits
❑Yes ❑No
Child Support
❑Yes ❑No
Interest/dividends from assets, including bank accounts
❑Yes ❑No
❑Yes ❑No
Social Security
Direct Sales Consulting such as Mary Kay, Tupperware,
Pampered Chef, etc.
❑Yes ❑No
Help with paying bills or other
❑Yes ❑No
Work for cash (babysitting, lawncare, etc.)
expenses or regular gifts of money
❑Yes ❑No
Any other source (if yes, explain below)
from family or friends who don’t live
with you (including online donations
such as GoFundMe or through a local
bank)
B.
Mark the ONE statement that applies to you:
I do not expect to have any source of income in the next 12 months.
I have been hired for a new job or I will be receiving another source of income soon. I will give you more information for
verification purposes.
C. If you have circled N for each source of income in section A, and you do not expect to have any
source of income in the next 12 months, explain how you will pay for the following:
(write N/A if the cost does not apply to your household)
Rent (including garage rent, if applicable)
Utilities
Food
Clothing
School supplies
Cell phone or phone
TV (cable, dish, satellite) and/or internet
Medical care
Medications & prescriptions:
Personal care products (shampoo, toothpaste, etc.)
Vehicle expenses (car payments, insurance, fuel, etc.)
Payments on credit card balances
Other expenses not listed above
Additional comments
Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge.
I further understand that providing false representations constitutes an act of fraud. False, misleading, or incomplete information may
result in the termination of my lease agreement. I understand that I may be required to periodically update this information as
requested by owner/agent.
Signature of Applicant/Tenant
Printed Name of Applicant/Tenant
Date
Certification of Zero Income (2019)
CERTIFICATION OF ZERO INCOME
(Each adult household member must complete this form.)
Head of Household Name:
Unit No.:
Development Name and Address:
A. Within the next 12 months, will you receive income from any of the following sources?
You must supply additional information to verify all ‘Yes’ answers.
❑Yes ❑No
❑Yes ❑No
Wages, bonus, commissions, tips, etc.
Self-employment (includes Uber/Lyft, online sales, etc.)
❑Yes ❑No
❑Yes ❑No
Unemployment Benefits
Annuities, insurance policies, stocks, etc.
❑Yes ❑No
❑Yes ❑No
Worker’s Compensation
Pensions, IRA, 401K
❑Yes ❑No
❑Yes ❑No
Disability Payments
Income from rental property
❑Yes ❑No
❑Yes ❑No
Alimony
Death Benefits
❑Yes ❑No
Child Support
❑Yes ❑No
Interest/dividends from assets, including bank accounts
❑Yes ❑No
❑Yes ❑No
Social Security
Direct Sales Consulting such as Mary Kay, Tupperware,
Pampered Chef, etc.
❑Yes ❑No
Help with paying bills or other
❑Yes ❑No
Work for cash (babysitting, lawncare, etc.)
expenses or regular gifts of money
❑Yes ❑No
Any other source (if yes, explain below)
from family or friends who don’t live
with you (including online donations
such as GoFundMe or through a local
bank)
B.
Mark the ONE statement that applies to you:
I do not expect to have any source of income in the next 12 months.
I have been hired for a new job or I will be receiving another source of income soon. I will give you more information for
verification purposes.
C. If you have circled N for each source of income in section A, and you do not expect to have any
source of income in the next 12 months, explain how you will pay for the following:
(write N/A if the cost does not apply to your household)
Rent (including garage rent, if applicable)
Utilities
Food
Clothing
School supplies
Cell phone or phone
TV (cable, dish, satellite) and/or internet
Medical care
Medications & prescriptions:
Personal care products (shampoo, toothpaste, etc.)
Vehicle expenses (car payments, insurance, fuel, etc.)
Payments on credit card balances
Other expenses not listed above
Additional comments
Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge.
I further understand that providing false representations constitutes an act of fraud. False, misleading, or incomplete information may
result in the termination of my lease agreement. I understand that I may be required to periodically update this information as
requested by owner/agent.
Signature of Applicant/Tenant
Printed Name of Applicant/Tenant
Date
Certification of Zero Income (2019)