STATEMENT OF NO INCOME FORM

 

 

 

TO BE FILLED OUT ONLY IF YOU DO NOT HAVE AN INCOME!

 

 

 

 

 

 Date:  __________________________

 

 

 

 

I, _________________________________________________, have not received any income since

                                                (Printed Name)

 

______________________________.

(Date)

 

 

            Please list how you pay the following (example:  “my mother pays”):

 

                        Rent:    _________________________________________

 

                        Food:    _________________________________________

 

                        Car Insurance:    __________________________________

 

                        Utilities:            ___________________________________

 

 

Signed under pains and penalties of perjury:

 

 

 

_______________________________________________

Signature