29A - SMALL BUSINESS INCENTIVE PROG

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CITY OF SANTA ANA SANTA ANA SMALL BUSINESS INCENTIVE PROGRAM DECLARATION OF INCOME Applicant Name: Income for: A Declaration of Income should be filled out for the head of household and each working member of the household. Check only one box and complete only that section ❑ I certify, under penalty of perjury, that I currently receive the following income: Income source: Amount: Frequency: Income source: Amount: Frequency: Income source: Amount: Frequency: ** Employment income should include the total income, before taxes and deductions are taken out. Freauenev Key Paid weekly: 52 times /year Paid every other week (biweekly): 26 times /year Total Monthly income: Paid twice a month (semimonthly): 24 times /year Total Expected Annual income: Paid monthly: 12 times /year Please attach any relevant documentation of this household member's income that you collected such as bank statements, pay stubs and tax returns. Remember, one of these forms should be filled out for the head of household and each working member of the household. I certify, under penalty of perjury, that I have no other income or assets other than what I have stated above. Applicant Signature: Date: ❑ I certify, under penalty of perjury, that I do not have any income from any source at this time. Applicant Signature: Staff Verification Staff Signature: 29A -20 Date: Date: