Clients with no income at the time of application must sign and date a self-declaration form attesting to that fact. The case worker must also sign and date that form. For ongoing CSBG clients, this form must be dated within one month from the date of application and monthly thereafter if there is no change in the client’s income.
Missing Required Documents: I do hereby declare under penalty of perjury that I do not have copies of the required documentation.
No Household Income: I do hereby declare under penalty of perjury that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by or the reason you cannot provide all required documentation: Examples: (Natural Disaster, Stranded, COVID-19, fleeing abusive household)
If client signatures cannot be obtained due to social and physical distancing measures, such as intakes and consultations occurring via telecommunications, a verbal self-attestation from the client can stand in place of a physical wet signature. Only check the box below if verbal self-attestation from the client was given. Indicate on the intake form and any other applicable intake materials that verbal attestation from the client was given, with a date stamp.
Verbal attestation from client was given in place of an electronic or physical wet signature.
Should be Empty: