Loss Prevention A Business

STATE OF CONNECTICUT

PARTMENT OF HOUSING

ila Mosquera-Bruno

Ned Lamont

Governor ‘Commissioner

CERTIFICATION OF ZERO INCOME

1) [hereby certify that do not individually receive income from any of the following sources:

a. Wages from employment (including commissions, tips, bonuses, fees, etc.

bb Income from operation of a business;

. Rental income from real or personal property;

d. Interest or dividends from assets;

e. Social Security payments, annuities, insurance policies, retirement funds, pensions, or death

benefits;

£. Unemployment or disability payments;

. Public assistance payments;

fh. Periodic allowances such as alimony, child support, or gifts received from persons not living in

my household;

i. Sales from self-employed resources (Avon, Mary Kay, Pampered Chef, etc.);

. Any other source not named above.

2) currently have no income of any kind and there is no imminent change expected in my financial status

‘or employment during the next three (3) months.

3) currently use the following sources of funds to pay for rent and other necessities (If applicable):

Under penalty of perjury, certify that the information presented in this certification is true and accurate to the best of

e. The undersigned further understands) that providing false representations herein constitutes an act of

fraud. Fal incomplete igformation may result in the termination of a lease agreement.

Sakari pina 5-7-24

Signature of Applicant/Tenant Printed Name of Applicant/Tenant Date

Signature of Co-Applicant/Co-Tenant Printed Name of Co-Applicant/Co-Tenant Date

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505 Hudson Street Hartford, CT 06106 www.ct.gov/doh

An Affirmative Action/E qual Employment Opportunity Employer

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