LIHEAP ZERO INCOME STATEMENT FORM
APPENDIX I
LIHEAP ZERO INCOME STATEMENT FORM
Date:
I, (Full Name)
, (SSN)
do hereby certify that I am unemployed and have no income for the following reason:
(check appropriate reason(s)
_ Laid off. Enter month and year of last date worked
The job I had was seasonal and has ended
I am unable to find employment
I have been or am, (circle one) sick / injured and unable to return to work.
I expect to return to work by (month/year)
I have small children and no one to care for them except me
My only source of income is from
I am no longer eligible for Unemployment Benefits
_ I receive assistance from the La. Dept. of Social Services
(circle all that apply) Food Stamps, TANF funds, OTHER:
Other (please use the space below to write any conditions that are not covered above)
I understand that if I knowingly give incomplete, inaccurate, or incorrect information I am subject
to criminal prosecution under Title 18 of the U.S. Code.
Signature:
Client Signature
Agency Representative
NOTE: THIS FORM SHOULD BE COMPLETED FOR ALL ADULT HOUSEHOLD MEMBERS 18 YEARS OF
AGE OR OLDER WHO REPORT ZERO INCOME.
Effective: January 1, 2022
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