Workers Compensation Mortgage
Resume:
SELF-DECLARATION OF ZERO INCOME
Applicant’s Name: (please PRINT) Last 4 digits of SSN:
Applicant’s Address:
Applicant’s Phone Number:
I declare that I currently receive zero income from employment, TANF/POWER, self-employment, retirement benefits, unemployment insurance benefits, workers compensation benefits, child support, social security, alimony, per capita benefits, VA benefits, or any other source(s) of income. Explain how you are paying for your household needs below (do NOT list dollar amounts): For example: Rent/Mortgage, Food, Utilities, Transportation, Phone, and Household Necessities. If money is received from others, please include a letter from the person(s) stating frequency and amount. I am taking the following actions to improve my current financial situation: Applied for or receiving SNAP Applied for or receiving TANF/POWER Budget/Financial Counseling Registered with Workforce Services Reduced monthly expenses Implemented Household Budget Reduced Energy Consumption Applied for Unemployment Benefits Other (Explain)
By my signature on this form, I swear/affirm that all information contained in the application and this form is true, correct, and complete, to the best of my ability, knowledge, and belief. Signature: Date:
LIEAP ID: {hhid} Revised 03/22/2019
Kendra Peterson
42 Riverview Cutoff Riverton Wyoming 82501
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I am currently waiting for my disability application to be processed and am currently looking for some type of job to try to better my situation. I am behind on all bills but live in a mobile home that I am renting from my ex in laws and they have let me stay although I have not been able to pay anything.
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Kendra Peterson 02/22/2022
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