SAMPLE UNEMPLOYED AFFIDAVIT

Before me this ___ day of ____________, 20__, personally appeared ____________________, who, being duly sworn, deposes and says:

1.

Check (a) or (b), as applicable: _______________(a) I am not presently employed, but anticipate becoming employed within the next 12 months. I am not presently employed, and do not anticipate becoming employed within the next 12 months.

_______________(b)

2.

Based on my past work experience, skills, and income history as reflected in my income tax return for the most recent tax year (copy attached), and with adjustments to reflect circumstances anticipated within the next 12 months, I expect to earn $_________ per year when I become employed. _________________________________ Signature of Applicant/Resident _________________________________ Date

__________________________________ Printed Name of Applicant/Resident

STATE OF PENNSYLVANIA COUNTY OF Before me personally appeared ______________________ who acknowledged to me that he/she/they executed the foregoing instrument this _____ day of ____________, 20____.

(NOTARIAL SEAL)

_________________________________ Notary Public Printed Name _________________________________ Notary Public Signature My Commission Expires: _________________________________

WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense for any person to make false or fraudulent statements to any department or agency of the United States Government or public housing authority as to any matter within its jurisdiction or to make unauthorized disclosures or improper use of the information collected hereunder.
May 2009