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Self-Declaration of Income

Full Name:
Email:
Average Gross Monthly Income ($):
Job Title:

Please provide your adjusted gross income for the previous 4 months

1st Month:
1st Month Income:
2nd Month:
2nd Month Income:
3rd Month:
3rd Month Income:
4th Month:
4th Month Income:

If unable to provide check stubs or a letter from your employer, please state the reason(s) why:

I feel that my employment will be at risk should my employer be contacted:
My employer/clients pay me in cash or check:
I am a day laborer/seasonal worker and my income fluctuates with the availability of work:
My only income is child support support paid in cash or personal check from child's other parent:
If checked above, state the amount of child support:
My only income is spousal support paid in cash or personal check from whom I am separated/divorced:
If checked above, state the amount of spousal support:
A family member, other than my spouse supports me:
If checked above, please explain and state the amount ($):
I currently have $0 income:
If checked above, please state the reasons why your income is $0:

If your income is $0, please explain how you are living (i.e. who pays the bills, how you get food, necessities, etc)

My spouse supports me financially:
A family member other than my spouse supports me:
If checked above, please explain what your family member provides:
I am a minor. I receive support from my family:
If checked above, please explain what support you receive from your family:
Other:
If checked above, please explain:
I DID NOT FILE a federal or state tax return last year:
I attest and declare under penalty of perjury and the laws of California that the above Self-Declaration of Income is true and correct.
eSignature:
Parent/Guardian eSignature (if applicable):
Date:
By checking this box, I am certifying that the above information is true and correct: