Weatherization-Certification-of-Household-Income

Affidavit Certifying Household Income
Name Last four numbers of Social Security number Gender Age Income
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I certify that I have declared all members of my household presently residing in my place of residence and have provided all sources and amounts of income for all persons living in my household to Southeast Energy Assistance. I also understand that, “A person who knowingly and willfully falsifies, conceals or covers up a material fact, or makes a false, fictitious or fraudulent statement” is subject to punishment, fine and imprisonment by federal and state agencies.
Printed Name
Signature
Clear
Date
MonthDayYear
Date
Please choose to indicate if you have or have not received LIEHEAP and if there is a smoker in the home.
LIHEAP assistance
YESNO
Smoker In House
YESNO
Should be Empty:

	Name	Last four numbers of Social Security number	Gender	Age	Income
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2
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5
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9
10

Affidavit Certifying Household Income