1. I hereby certify that my
household does not receive income from any of the following sources:
a. Wages from employment
(including commissions, tips, bonuses, fees, etc.).
b. Income from operation of a
c. Rental income from real or
d. Interest or dividends from
e. Social Security payments,
annuities, insurance policies, retirement funds, pensions, or death benefits.
f. Unemployment or disability
g. Public assistance payments.
h. Periodic allowances such as
alimony, child support, or gifts received from persons not living in my
i. Sales from self-employed
resources (Avon, Mary Kay, eBay, etc.).
j. Any other source not named
2. My household currently has no
income of any kind and there is no imminent change expected in my financial
status or employment status.