Executive Director Community Services

Put Notary stamp below, if needed (DOE only) or have

Executive Director Sign here

Department of Community Services and Development

CSD 43B (rev.12/2013)

CERTIFICATION OF INCOME AND EXPENSES

You are being asked to complete this form because you requested assistance, and state that your entire household cannot provide proof of income. The State of California requires the applicant to report all sources of income. This form will help us understand how you are meeting expenses. Please complete the information below: Name and Address

Name:

Address:

Section 3: Please tell us how you paid these monthly expenses during the previous months: EXPENSE

MONTHLY

COST

HOW HAS THE EXPENSE BEEN PAID? IF SOMEONE ELSE PAYS FOR YOU, PLEASE COMPLETE: Rent or

Mortgage

$

Name: Phone:

Address:

Utility

Bills

$

Name: Phone:

Address:

Food $

Name: Phone:

Address:

Section 4: If none of the above applies to you, please explain how your monthly expenses were paid: Signature:

By signing this form, I affirm that I believe these facts are accurate and true. I give the Service Provider my permission to verify this information. I may be held liable under federal or state law for knowingly making false or fraudulent statements. Signature Date

Section 1: Do you have sources of income you forgot to report? YES NO During the previous month have you been employed part time? YES NO During the previous month have you been self-employed? YES NO

During the previous month did you receive money for any work that you perform only once in a while, like yard work, child care, donating blood, etc?

YES NO

During the previous month have you received any gifts of money from anyone? If yes, please list the name and phone number of the person who gave you the gift:

YES NO

During the previous month did you receive any of the following: (circle any that apply) WORKER’S COMP UNEMPLOYMENT GOVERNMENT SPONSORED BENEFITS CHILD SUPPORT YES NO

Do you receive any of the following (circle any that apply) ANNUITY PAYMENT PENSION TRIBAL CASINO PAYMENTS RENTAL INCOME INSURANCE BENEFITS Section 2: Are you spending your savings or borrowing money to cover monthly expenses?

YES NO

Are you using savings or a home equity loan?

How much?

YES NO

Are you using some other asset?

How much?

YES NO

Are you borrowing from credit cards?

How much?

YES NO

Are you borrowing from some other source?

How much?

ONLY FILL OUT THIS FORM IF NO ADULT

IN THE HOME HAS AN INCOME

X

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