90 Day Certification of Zero Income - NHE



NHE, Inc.

(PROPERTY NAME)

90-DAY TRACKING OF NO-INCOME

Residents claiming no-income re-certify quarterly that they are still not receiving income from any sources. If they are now receiving income please have them complete a Statement of Income form and note the change on this form.

My signature below indicates that I certify that I am still not receiving any income from any sources.

|MONTH |SOURCE OF INCOME |AMOUNT OF INCOME (Gross Amount) |IF STOPPED, WHY? |

| |(e.g., Employer, ADC, Support) |(Self-Employed, Family, etc.) | |

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PLEASE READ:

By my signature I certify that the information I have provided above is true and complete to the best of my knowledge and belief. I understand that if I furnish false or incomplete information I can be fined up to $10,000 or imprisoned up to five years, or lose the subsidy HUD pays and/or have my rent increased.

Signature: Printed Name:

Apartment #: Date:

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