Income Reporting Form

All adult household members reporting zero income must complete this form on a quarterly basis

Please answer the following questions honestly and completely.

Food Expenses

Is Any Member of The Household Receiving Food Stamps?

Yes
No

If, yes what is the value of the food stamps? Amount($)

What is your household's monthly grocery bill?

If there are additional groceries not covered by food stamps, how does your family pay for them?

If someone other than a household member gives you cash for the groceries, who is it?

What is the average cash monthly amount for groceries given to you? Amount($)

Does anyone give groceries or prepared food to your family?

Yes
No

If yes, what is the approximate cost of the food/groceries? Amount($)

Cleaning, Grooming And Paper Product Expenses

What is the monthly estimated cost of paper products used by your family? Include paper napkins, toilet paper, paper towels, trash bags, disposable diapers and other paper goods? Amount($)

How does your household pay for these products?

If someone other than a household member providing paper products to your family, who is it?

How much money does someone give your household to buy paper products on a monthly basis? Amount($)

Does anyone provide paper products to your family?

Yes
No

If yes, what is the average monthly value of paper products provided to the family? Amount($)

What is the monthly estimated cost of grooming products and services used by your household? Include soap, deodorant, toothbrushes, dental floss, toothpaste, shampoo, hair color, beautician & barber services, manicures. Amount($)

How does your household pay for the cost of grooming products and services?

If someone other than a family member of the household provides grooming products, who is it?

What is the average monthly value of contributions (cash or products) this person provides for grooming products?

What is the monthly estimated cost of cleaning products used by your household? Include dishwashing soap, laundry detergent, and household cleaning products. Amount($)

How does your household pay for cleaning products?

If someone other than a member of the household provides cleaning products, who is it?

What is the average monthly value of cash contributions given to your household for cleaning products? Amount($)

Does anyone provide cleaning products to your household?

Yes
No

If yes, what is the average monthly value of cleaning products provided to the family? Amount($)

Transportation Expenses

Does your family own a car? (If no, skip to Question Upto If your household does not have a car, what do you use for transportation?)

Yes
No

If yes, are there still payments due on the car?

Yes
No

If yes, what is the amount of the monthly car payment?

How does the family make the car payment?

If someone other than a member of the household makes the car payment, who is it?

What is the monthly amount that the person listed above pays toward the car payment? Amount($)

What is the average monthly cost for gas to operate your vehicle? Amount($)

What is the average annual cost for maintenance on your vehicle? Amount($)

What is the average annual cost of tires? Amount($)

What is the average annual cost for insurance on this vehicle?

How does your household pay for the above auto-related expenses?

If someone other than a member of the household contributes to the car's operating cost, who is it?

What is the average monthly amount of cash or direct payment contribution to the car’s operating costs? Amount($)

If your household does not have a car, what do you use for transportation?

How does your household pay for transportation?

What is the average monthly transportation cost for your household? Amount($)

If someone other than a member of the household contributes to other transportation costs, what is the average monthly amount of cash or other contribution to transportation? Amount($)

Entertainment Expenses

Does your family have cable TV or satellite connection? (if no, skip to Question upto What are the average monthly cost of other types of entertainment for your household)

Yes
No

What is the average monthly cost of cable TV/satellite service? Amount($)

How does your household pay for the cable TV/satellite service?

If someone other than a member of your household pays for the cost of your cable TV/satellite service, who is it?

What is the average monthly payment (In cash or direct payment to the cable company) this person pays for your cable TV/satellite service? Amount($)

What are the average monthly cost of other types of entertainment for your household? Includes the following: magazines, movies, video rentals, club memberships, sporting events, lottery tickets, concerts, liquor/beer/wine, vacations, or other entertainment. Amount($)

How does your household pay for entertainment costs?

If someone other than a member of your household contributes to the cost of other entertainment, who is it?

What is the average monthly estimated cost for clothing and shoes for your family? Amount($)

How does your family pay for clothes and shoes?

If someone other than a member of the household contributes to the cost of clothing, who is it?

What is the average monthly contribution (in cash or actual items) for clothing? Amount($)

Does anyone in your household smoke cigarettes or cigars?

Yes
No

If yes, how many packs per day are smoked by the smoker in the household?

How does your household pay for the cost of cigarettes/cigars?

If someone other than a member of the household contributes to the cost of smoking, who is it?

What is the average monthly contribution in cash, cigarettes, or cigars? Amount($)

Communication Expenses

Does your family have a telephone?

Yes
No

If yes, how many lines does the family have in the unit? # of Lines

Does your family have any special telephone services? For example, call waiting, call forwarding, caller ID, etc.

Does anyone in your household have a cell phone?

Yes
No

What is the monthly cost for telephone service? Amount($)

How does your household pay for the cost of telephone service?

If someone other than a member of the household contributes to the cost of telephone service, who is it?

What is the average monthly contribution (In cash or direct payment to the telephone company) this person provides for telephone service? Amount($)

Does anyone in your household have a computer?

Yes
No

Does anyone in your household have internet connection?

Yes
No

If yes, who is the internet provider?

What is the monthly cost of the internet connection? Amount($)

How does your household pay for internet connection?

If someone other than a member of the household contributes to the cost of internet connection, who is it?

What is the average monthly contribution (in cash or direct payment to internet provider) this person pays for internet services? Amount($)

Housing And Utility Expenses

What is the average monthly cost for your housing? Amount($)

What is the average monthly cost for your utility? Amount($)

How does your household pay for the cost of housing and utilities?

If someone other than a member of the household makes a contribution toward housing and utility costs, who is it?

Miscellaneous Expenses

How much does your household spend per year on the following expenses? Includes the following: church contributions, unreimbursed educational, child care, job or medical expenses, pet expenses or other expenses. Amount($)

Zero Income Verification

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.

Food Expenses

Cleaning, Grooming And Paper Product Expenses

Transportation Expenses

Entertainment Expenses

Clothing Expenses

Smoking Expenses

Communication Expenses

Housing And Utility Expenses

Miscellaneous Expenses

Zero Income Verification