All adult household members reporting zero income must complete this form on a quarterly basis
Please answer the following questions honestly and completely.
I do hereby swear and attest that I currently have zero income and all the information provided on this form is true and correct. I understand that I am obligated to complete this form on a quarterly basis for as long as I do not have income and it is my responsibility to request this form from the Paragould Housing Authority. I also understand that all changes in my income and the income of any member of the household must be reported to the Poinsett County Housing Authority in writing within ten(10) days of a change. I must complete the Zero Income Form and provide documentation of all changes in income. I also acknowledge that the Poinsett County Housing Authority will contact the Department of Labor and Employment to verify my unemployment. Also, any addresses and phone numbers I provide on this document I give my permission for Release of Information to that individual (s).
WARNING: TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES.