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  • ERAP Self Declaration Form

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    Cody Clauson
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    This document is a self-declaration of income form for a client applying for assistance from the Community Action Council's ERAP program. The client provides information about their income type by checking boxes, including wages, self-employment, pensions, government assistance, and other sources. They sign to certify the information is accurate and understand legal penalties for providing false information. A staff member also signs and dates upon receiving the completed form.

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    Original Title

    1606906996611_ERAP Self Declaration Form

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    This document is a self-declaration of income form for a client applying for assistance from the Community Action Council's ERAP program. The client provides information about their income type by checking boxes, including wages, self-employment, pensions, government assistance, and other sources. They sign to certify the information is accurate and understand legal penalties for providing false information. A staff member also signs and dates upon receiving the completed form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    24 views2 pages

    ERAP Self Declaration Form

    Uploaded by

    Cody Clauson
    This document is a self-declaration of income form for a client applying for assistance from the Community Action Council's ERAP program. The client provides information about their income type by checking boxes, including wages, self-employment, pensions, government assistance, and other sources. They sign to certify the information is accurate and understand legal penalties for providing false information. A staff member also signs and dates upon receiving the completed form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 2

    Community Action Council

    ERAP Program
    Self-Declaration of Income

    Type of income: Source(s), Amount(s) & Notes:

    ☐ No Income

    ☐ Wages and Salary


    Income

    ☐ Self-Employment
    and Business
    Income

    ☐ Pension/
    Retirement Income

    ☐ Unemployment/
    Disability Income

    ☐ TANF/
    Public Assistance

    ☐ Alimony, Child
    Support, Foster
    Care Payments

    ☐ Armed Forces
    Income

    CLIENT NAME: CLIENT ID:

    I certify that the information in this Self Declaration statement is complete and accurate to
    the best of my knowledge. I understand that I am signing this document under penalty of
    criminal prosecution if I knowingly give false information that results in assistance in
    which I am not eligible.

    Client Signature Date


    Community Action Council
    ERAP Program
    Self-Declaration of Income

    Staff Signature Date

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