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:
] [ ]
Text
Is your household responsible for water service?
City/State/Zip:
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_______________________