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