DECLARATION OF EMPLOYMENT LOSS
Head of Household Name: _______________________________________________________
Last 4 of Social Security Number: XXX-XX-____________________________________________
Address: ______________________________________________________________________
This is to certify that I, __________________________________, have ended employment at _________________________________ (company name.) My last day of work was __/__/____. By signing this form, I am certifying that I have no wage income, and I do not anticipate having wage income in the next 30 days. I understand that if I do gain any additional income, I must report the change in Rent Café within 10 days. I/we certify that the information given to Metro West Housing Solutions (MWHS) on household composition, income, net family assets and allowance and deductions is accurate and complete to the best of my/our knowledge and belief. I/we understand that we are required to report any changes in household composition, income, net family assets and allowance and deductions in Rent Café within 10 days of the change. I/we also understand that false statements or information are punishable under federal law as well as grounds for termination of housing assistance or tenancy. I/we have no objection to inquiries for the purpose of verification. I/we understand that if a tenant submits fraudulent information to this agency or withholds relevant information from this agency, the resident will be charged back rent, may be terminated from assisted housing and may be turned in for prosecution for violating a federal law.
Signature: ________________________________ Date: _____________________________________
WARNING: TITLE 18, SECTION 1001 OF THE U.S. CODE STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDLENT STATEMENTS TO ANY DEPARTMENT OF THE UNITED STATES GOVERNMENT.
ALTERNATIVE FORMATS OF THIS DOCUMENT ARE AVAILABLE UPON REQUEST.
575 Union Blvd Suite 100, Lakewood, Colorado 80228 ● Phone 303-987-7580 ● TTY 711 ● www.mwhs.org