CDBG-CV Microenterprise Assistance Program funds

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ZERO INCOME AFFIDAVIT

(To be completed by adult household members (18+ years old) only, if appropriate.)

Address*

hereby certify that I do not receive income from any of the following sources: 

a. Wages from employment (including commissions, tips, bonuses, fees, pay in lieu of vacation or sick time, profit sharing, etc.). 

b. Income from operation of a business. 

c. Rental or royalty income from real or personal property or gain from the sale of a property. 

d. Interest or dividends from assets. 

e. Social Security payments (SSI/SSDI), annuities, insurance policy benefits, distributions from retirement funds, pensions, or death benefits. 

f. Unemployment or disability payments. 

g. Severance pay. 

h. Public assistance payments (Child support, General assistance). 

i. Periodic allowances such as alimony, child support, or regular periodic gifts received from persons not living in my household. 

j. Veteran’s benefits. 

k. Gambling winnings. 

I currently have no income of any kind and there is no imminent change expected in my financial status or employment status during the next 12 months. 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 herein constitutes an act of fraud. I acknowledge the information provided is being used for the specific purpose of determining eligibility to receive assistance through the Jersey City Economic Development Corporation CDBG-CV Microenterprise Assistance Program. If requested, I will fully cooperate with any request to provide documents to verify the information provided within.

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