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Self-Certification

Full Name:
Date:

Statement Under Penalty of Perjury

1. The agency has requested that I complete this form because my employer has refused or failed to provide requested employment information. Complete Section A:
2. I have asked that my employer not be contacted to verify my employment because that contact could put my employment at risk. Compete Section A:
3. I am a self-employed. Complete Section A:
4. I have no paystubs, receipts, or other documentation of employment. Complete Section A:
5. Non-employment income when no documentation is possible. Complete Section B:
6. The child(ren) father(s) does/do not live with me and the children. Complete Section C:
7. Other. Complete Section D:

Section A - Employment

Employer:
Type of Work:
Date of Hire:
Rate of Pay:
How Often Paid:
Description of Work:

Hours and Days of Work

Indicate am or pm for start and end times

Monday

Start Time:
End Time:

Tuesday

Start Time:
End Time:

Wednesday

Start Time:
End Time:

Thursday

Start Time:
End Time:

Friday

Start Time:
End Time:

Saturday

Start Time:
End Time:

Sunday

Start Time:
End Time:

Section B - Non-employment Income

Type of Income:
How Much:
How Often:

Section C - Residence (You need to provide proof of residence)

Your Address

Address:
City:
State:
Zip:

Father's Address

Address:
City:
State:
Zip:

Section D - Other

Please explain:

By checking this box, I am certifying under penalty of perjury, that the above information is true and correct: