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(T)ATHOLIC <br />CHARITIES <br />Of OMNGEOUN'IY <br />pm'hmih" 0 1; <br />Safely Home in Santa Ana <br />Eviction Prevention Program <br />INCOME VERIFICATION AFFIDAVIT <br />The Income Verification Affidavit: <br />CAN BE USED FOR <br />• For household members who receive <br />cash payment for work, and do not have <br />any proof of income: <br />Example: Day laborers, self employed <br />• For household members who receive <br />money from sources such as family and <br />friends, recycling. <br />• Mandatory use of this form <br />If the applicant is claiming the total <br />household income is $0 <br />CANNOT BE USED FOR <br />• Employed household members who are <br />paid with checks and have paystubs <br />• Household members who receive Social <br />Security, SSI, SSP, public assistance, <br />disability, workers compensation, <br />unemployment, pension, interest, or any <br />other income with documented proof. <br />Please provide the name of the person who is utilizing the income affidavit as proof of <br />income, supply the total amount received, and check the box for proof of income. <br />1. Name: $ Month <br />❑ Paid with cash / ❑ Family cash assistance / ❑ $0 Household Income <br />$ Month <br />❑ Paid with cash / ❑ Family cash assistance / ❑ $0 Household Income <br />3. Name: $ Month <br />❑ Paid with cash / ❑ Family cash assistance / ❑ $0 Household Income <br />By signing below, I certify under penalty of perjury under the laws of the State of <br />California that this information is true and correct. <br />Applicant Signature: Date: <br />