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Zero Income Declaration Form

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mylife122260
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25 views2 pages

Zero Income Declaration Form

Uploaded by

mylife122260
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

1540 Webster St.

Oakland, CA 94612

Client #:
Recertification Month:

Zero Income Declaration


The person named below MUST complete this form.

Name: SSN:

Please answer all of the following questions. Incomplete declarations will not be accepted:

Mark [X] “YES” or “NO” and provide the information requested:


YES NO

[ ] [ ] Do you pay rent? Monthly Rental Portion:


Who pays your portion (Name/Agency): Phone Number:
Address: City/State/Zip:

[ ] [ ] Is your household responsible for PG&E service? Average Monthly Cost:


Who pays this bill (Name/Agency): Phone Number:

Address: City/State/Zip:

[ ] [ ] Is your household responsible for water service? Average Monthly Cost:


Who pays this bill (Name/Agency): Phone Number:

Address: City/State/Zip:

[ ] [ ] Do you purchase food/groceries? Average Monthly Cost:


Who pays for this (Name/Agency): Phone Number:

Address: City/State/Zip:

[ ] [ ] Do you purchase household goods and toiletries (toilet paper,


toothpaste, soap, deodorant, laundry soap, cleaning supplies)? Average Monthly Cost:
Who pays for this (Name/Agency): Phone Number:

Address: City/State/Zip:

[ ] [ ] Do you purchase any personal extras or necessities a month


(clothing, shoes, hair cuts, beauty supplies, cigarettes, etc.)? Average Monthly Cost:
Who pays for this (Name/Agency): Phone Number:

Address: City/State/Zip:

[ ] [ ] Do you use public coin-operated laundry facilities? Average Monthly Cost:


Who pays for this (Name/Agency): Phone Number:

Address: City/State/Zip:
YES NO

[ ] [ ] Does your household have a home telephone? Average Monthly Cost:


Who pays this bill (Name/Agency): Phone Number:

Address: City/State/Zip:

[ ] [ ] Do you have a cell phone? Average Monthly Cost:


Who pays this bill (Name/Agency): Phone Number:

Address: City/State/Zip:

[ ] [ ] Does your household have cable/satellite television service? Average Monthly Cost:
Who pays this bill (Name/Agency): Phone Number:

Address: City/State/Zip:

[ ] [ ] Does your household have internet service? Average Monthly Cost:


Who pays this bill (Name/Agency): Phone Number:

Address: City/State/Zip:

[ ] [ ] Do you have any credit/charge accounts? Average Monthly Cost:


Who pays this bill (Name/Agency): Phone Number:

Address: City/State/Zip:

[ ] [ ] Do you use public transportation (BART, AC Transit)? Average Monthly Cost:


Who pays for this (Name/Agency): Phone Number:

Address: City/State/Zip:

[ ] [ ] Do you own or lease a car? If you own or lease a car, how much is the:
Monthly Car Payment:
Monthly insurance premium:
Monthly Average Gas Usage:
Annual Registration Fee:
Annual Upkeep (Oil Changes, Tune-Ups, Etc):
Who pays for this (Name/Agency): Phone Number:

Address: City/State/Zip:

I fully understand that if or when I become eligible for any type of income and/or assistance, or accept temporary,
part or full-time employment, I must report this to OHA in writing within fourteen (14) business days.

I understand that because I presently rely on loans, gifts, donations or other irregular income sources, OHA may
require an interim re-examination of income at anytime prior to my next annual re-examination and this may increase
my rent. I understand that OHA may run my credit report to determine whether the income information I have
supplied to OHA is consistent with what is reported in my credit history.

By signing below, I am certifying under penalty of perjury, that I have completed the zero income form and the
provided information is true and complete.

Signature____________________________________________ Date_______________________

Common questions

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The rationale behind OHA's ability to request interim re-examinations of income stems from the need to ensure that housing assistance reflects the current financial situation of the recipient. Given that individuals may have irregular income sources, OHA needs to verify and adjust rent calculations accordingly to maintain fairness and accuracy in their assistance programs. This allows OHA to ensure that participants are receiving the correct level of assistance based on up-to-date information .

The zero income declaration form is effective in capturing a comprehensive financial picture by systematically verifying both income sources and expenditure details, but it relies heavily on self-reported information that may not always be accurate. While the form captures a wide range of financial activities—from income to monthly expenses—it requires thorough cross-verification (such as potential credit checks) to ensure all information is accurate and reflective of the current financial status of the applicant's household, thus influencing the effectiveness of the assistance decisions made by OHA .

The potential consequences of OHA running a credit report might include uncovering discrepancies between reported and actual income sources. This could lead to rent recalculations, changes in the assistance level, and possible disciplinary actions if inconsistencies suggest fraudulent reporting. It also serves as a deterrent against misreporting, encouraging accurate information disclosure by applicants aware that their credit history will be examined for inconsistencies .

Not adhering to the requirement of reporting income changes within the fourteen business days could result in financial and legal consequences for the individual. Financially, it could mean that the individual is underpaying rent if their ability to pay has increased, leading to a debt with OHA. Legally, it could result in penalties since the declaration signed by the individual is under penalty of perjury, implying severe repercussions for misreporting or fraudulent declarations .

OHA recognizes income from various sources that need to be reported, including loans, gifts, donations, employment income (temporary, part-time, or full-time), and any forms of assistance. These sources must be reported because they can impact the level of assistance received and any rent calculations. Accurate reporting ensures compliance with OHA guidelines and prevents discrepancies that might arise from unreported income .

It might be necessary for an individual's rent to increase according to the zero income declaration form policy if there is a change in the person's income status due to obtaining employment, receiving assistance, or any other financial support. When these changes occur, they can affect the individual's ability to pay more rent, leading to a recalibration of the rent amount that aligns with the updated financial situation .

OHA ensures the accuracy of the income information by potentially conducting credit checks to verify that the data provided by individuals is consistent with their credit history. This practice is done to confirm that the information matches what is available on their credit report and to identify any undisclosed income sources that need to be reported .

It is important to report any changes in income to OHA within fourteen business days because it affects the calculation of rent. Failure to report these changes can result in incorrect rent assessments, and because income from loans, gifts, or donations can be irregular, it is critical to provide timely updates. Additionally, interim re-examinations may be required by OHA if income sources change, potentially leading to rent adjustments .

OHA might require detailed information about monthly expenses to accurately assess the financial needs and eligibility of the applicant for housing assistance. By understanding the total expenses related to rent, utilities, and transportation, OHA can comprehensively determine the financial burden on the household and ensure that the assistance provided meets the actual needs. This helps in designing assistance that is proportional and fair to the individual's financial situation .

The significance of the statement signed under penalty of perjury is that it legally binds the individual to the truthfulness and accuracy of the information provided on the form. Signing under this condition highlights the legal obligation to provide accurate information and deters fraudulent reporting. It serves as a legal safeguard for OHA, ensuring compliance and accountability, and subjects the signer to potential legal actions if false information is discovered .

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