ZERO INCOME VERIFICATION FORM
Instructions: do not leave any blanks. Answer every question on this form. If an area of this form does not apply to you, write the word “none.” Incomplete forms will be returned and may delay your assistance. Mail, upload or bring this form back to MWHS within 10 days of receipt.
Please list all household members:
| Name | Date of Birth | Age | Gender |
|---|---|---|---|
Food Expenses
How does the family pay the grocery bill? ________________________________________________________
If someone other than a member of the household contributes, who contributes? _______________________
What is the average monthly cash value contributed from all sources? $________________________________
What is the monthly food stamp benefit amount? $________________________________________________
Paper Product Expenses
What is the monthly value of paper products used by the family? (include paper napkins, toilet paper, paper
towels, trash bags, disposable diapers and other paper goods.) $______________________________________
How does the family pay for these products? _____________________________________________________
If someone other than a member of the household contributes, who contributes? _______________________
What is the average monthly cash value contributed for these products? $______________________________
Personal Hygiene Expenses
What is the monthly value of personal hygiene products used by the family? (include soap, deodorant,
toothpaste, shampoo etc.) $___________________________________________________________________
How does the family pay for these products? _____________________________________________________
If someone other than a member of the household contributes, who contributes? _______________________
Cleaning Product Expenses
What is the monthly value of cleaning products used by the family? (include dish soap, laundry detergent and
other household cleaning products.) $___________________________________________________________
How does the family pay for the cost of these products? ____________________________________________
If someone other than a member of the household contributes, who contributes? _______________________
What is the average monthly cash value contributed for these products? $______________________________
Clothing Expenses
What is the monthly cost of clothing and shoes used by the family? $__________________________________
How does the family pay for the cost of clothing and shoes? _________________________________________
If someone other than a member of the household contributes, who contributes? _______________________
What is the average monthly cash value contributed for clothing and shoes? $__________________________
Transportation Expenses
Does the family own a car? ☐ Yes ☐ No If yes, are payments still 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 contributes to the car payment, who contributes? _______
If the family owns a car and no payments are due, what are the average monthly amounts the family pays for the following?
Gas $______ Maintenance $______ Insurance $______
How does the family pay for these auto-related expenses? __________________________________________
If the family does not own a car, what does the family use for transportation? ___________________________
How does the family pay for this transportation? __________________________________________________
If someone other than a member of the household contributes to other transportation costs, who contributes?
__________________________________________________________________________________________
What is the average monthly cash value of the contribution to transportation? $_________________________
Entertainment Expenses
How does the family pay for entertainment expenses such as cable, magazines, etc? _____________________
What are the average monthly costs for entertainment? ____________________ Include the following:
Magazines $______ Movies $______ Video Rentals $______ Cable $______ Vacations $______ Sporting Events $______ Internet Connection $______
Communication Expenses
Does the family have a telephone or cell phone? ☐ Yes ☐ No
What is the average monthly cost for telephone services? $__________________________________________
How does the family pay for the cost of the telephone service? ______________________________________
If someone other than a member of the household contributes to the cost of telephone service, who
contributes? ______________________________________________________________________________
Utility Expenses
Is your public service balance current? ☐ Yes ☐ No
What was the date of your last payment? _______________ What was the balance of your last bill? _________
What is the average monthly amount you pay for utility costs? $______________________________________
If someone other than a member of the household contributes to the cost of the utility service, who
contributes? _______________________________________________________________________________
Miscellaneous Expenses
Listed below are a series of expenses the family might have. Indicate the monthly amount the family spends on
any applicable expenses and the amounts contributed toward the expenses:
Un-reimbursed medical expenses $______ School Supplies $______ Pet Food $______
Television, furniture, washer, dryer rental $______
I/we certify that the information given to 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 writing within 10 days of their occurrence on the Rent Café portal.
I/we also understand that if a resident submits fraudulent information to this agency or withholds relevant information from this agency, the resident will be charged back rent, face eviction proceedings and will be turned in for prosecution for violating a federal law.
By signing below, I hereby certify all information provided is true and complete to the best of my knowledge.
Signature of Head of Household:_________________ Date:______________________
Other Family Member Age 18+:___________________ Date:______________________
Other Family Member Age 18+:___________________ 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
