Metro West Housing Solutions

Verification of Self-Employment

TO BE COMPLETED BY PARTICIPANT:

Participant Name: ___________________________________ Participant SSN: __________________________
Participant Address: _________________________________________________________________________
This certifies that I, _____________________________________________, earned a total of $_____________
from __________________ (date) to __________________ (date) doing the following work _______________
_________________________________________________________________________________________.
I expect to earn $_____________ in the next 12 months for the following work _________________________
_________________________________________________________________________________________.
Participant Signature: _____________________________________________ Date: ______________________

TO BE COMPLETED BY NOTARY:

Name of Notary Public: _________________________________ Date Commission Expires: ________________
Signature of Notary Public: ___________________________________ Date: ___________________________
Notary Public Seal:

 

 

WARNING: SECTION 1001 OF TITLE 18 OF THE U.S. CODE MAKES IT A CRIMINAL OFFENSE TO MAKE WILLFUL, FALSE STATEMENTS OF MISREPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE U.S. AS TO ANY MATTER WITHIN ITS JURISDICTION.

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