No Income Statement

Income Attestation

I certify that I currently have no earned household income. This includes income from employment, self-employment, or other regular sources of income. I understand that this statement is required to determine eligibility and award level for assistance through the STRIPE Program.

I further acknowledge:

• This information is true and correct to the best of my knowledge.
• If my household income changes during the application or review period, I will notify the program.
• Providing false or misleading information may affect my eligibility for current or future assistance.

Certification

By submitting this form, I affirm that the information provided above is accurate and complete.

Electronic Signature (Full Name):
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Date:
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