Self Certification of Income
No documentation is possible to verify my income or documentation is insufficient to
determine my income. Therefore, I am self-declaring my income for the previous 30 day
period.
Total Estimated Gross Income:________________
Rate of Pay (amount per hour, day, etc.):
$________per______
Pay Period: daily  weekly  every other week  two times a month  monthly
 Other: explain___________________________________________________________
Type of work performed:____________________________________________________________
Explain why documentation is inadequate or not possible for the income received and any additional information you
could provide so we may better understand your financial circumstance:
I declare and affirm under penalty of perjury that the statements made herein are true and
correct to the best of my knowledge, information and belief.
_________________________________
______________
____________________________________
Signature
Date
Name of Adult signing this form