I,   First Name   Last Name   , declare that I have been working and receiving payment in the form of cash in the amount of $   Amount   per (check one)   day   week   two weeks   month. I have no check stubs or other documentation to prove these earnings.

I, First Name   Last Name , declare that I have no employment and no income of any kind.

To the best of my knowledge, I attest the above information is true.