T-64 Zero Income Questionnaire 1 of 2 July 2019

NHE, Inc.

(INSERT PROPERTY NAME)

Resident Name: ________________________________________ Apartment #: __________________

ZERO INCOME QUESTIONNAIRE CERTIFICATION

This notice is to verify that I am presently unemployed and have no other source of income. I will report to the office IMMEDIATELY

when any changes occur in my employment or income status. I further understand that if I fail to report these changes immediately to the

office, and as a result I am charged a rent less than the amount required by HUD Rent Formulas, I agree to reimburse the Management for

the difference between the rent I should have paid and the rent I was charged.

YES NO

1. Do you have any other source of income except what you have stated in your application?

If yes, what source?

If yes, how much per month? $

2. Do you get any money from Social Security office?

3. Do you get any money from Human Services (DHS) (AFDC)?

4. Do you get any money from Unemployment office, any other governmental office?

5. Do you get any money from family, friends or charitable entity?

6. Do you get any money from child support?

7. Do you get any money from alimony?

8. Do you have any children over the age of 18 working and living at home?

9. Do any of your children receive money from Social Security?

10. Do you or anyone living with you receive any pension funds?

11. Do you receive any interest on CD’s or savings?

12. Are you paying a rental, lease or purchase payment for rented items (TV, VCR, Furniture, etc.)?

If so, how much per month? $

13. Do you drive a car which will be kept on the property? ________ If yes, do you make payments?

14. Do you make any other payments not covered above to any finance agency, credit card company or other

entity?

15. Do you have a home phone, cell phone or both?

16. Do you have cable TV/Satellite?

IF YOU HAVE NO INCOME FROM THE ABOVE, HOW WILL YOU PAY FOR THE FOLLOWING?

ITEMS COST PER

MONTH

INCOME SOURCE

Automobile(s) $

Gas for automobile $

State required automobile insurance $

Electricity $

Telephone or cell phone $

Cable (includes HBO, Cinemax) $

How do you plan to purchase the following?

Paper products – (toilet paper, paper plates, school supplies, Kleenex, etc.)?

Grooming Aids – (deodorant, toothpaste, soap, dish detergent, shaving

cream, etc.)?

Groceries (all other food, etc.)?

T-64 Zero Income Questionnaire 2 of 2 July 2019

I/we certify that these statements are true to the best of my/our knowledge and belief. I/we understand that I/we can be fined up to

$10,000 or imprisoned up to five years or have my/our lease at the above-named property terminated if I/we furnish any false or

incomplete or misleading information on this form.

I/we certify that I/we receive $ per month to help pay the above bills.

Applicant/Resident: Date:

Applicant/Resident: Date:

PENALTIES: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making

false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or

the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent

form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who

knowingly or willingly requests, obtains, or discloses any information under false pretenses concerning an applicant or participant

may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of

information may bring civil action for damages and seek other relief, as may be appropriate, against the officer or employee of HUD

or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number

are contained in the Social Security Act at 42 USC 208a (6), (7) and (8). Violations of these provisions are cited as violations of 42

USC 408a (6), (7) and (8).