ERUC Self-Declaration of Income

First Name *

Last Name *

This is to certify the income status for the above named individual. Income includes but is not limited to: • The full amount of gross income earned before taxes and deductions. • The net income earned from the operation of a business, i.e., total revenue minus business operating expenses. This also includes any withdrawals of cash from the business or profession for your personal use. • Monthly interest and dividend income credited to an applicant’s bank account and available for use. • The monthly payment amount received from Social Security, annuities, retirement funds, pensions, disability and other similar types of periodic payments. • Any monthly payments in lieu of earnings, such as unemployment, disability compensation, SSI, SSDI, and worker's compensation. • Monthly income from government agencies excluding amounts designated for shelter, and utilities, WIC, food stamps, and childcare. • Alimony, child support and foster care payments received from organizations or from persons not residing in the dwelling. • All basic pay, special day and allowances of a member of the Armed Forces excluding special pay for exposure to hostile fire. *

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Check only one box and complete form as approrpiate. *

I certify, under penalty of perjury, that I currently receive income and will provide the source, amount and frequency below.

I certify, under penalty of perjury, that I do not have any income from any source at this time.

Source of Income

Amount

Frequency

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