Self Declaration Form

Self Declaration Form
I certify that the documentation provided and the facts contained in this application are accurate and true to the best of my knowledge and understand that falsified statements on this application or in the documentation provided could result in being denied CSBG-funded assistance in Wyoming.
Signature*

Clear
Date*

MonthDayYear
Date
Self-Declaration for zero income or missing required documentation.

Only complete if you have no source of income or are missing any of the required documentation. Please check all that apply:
This Household has no source of income.

YesNo
I First Name Last Name, 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:
No Proof of Identification No Proof of Residency No Proof of Income
(I, First Name Last Name , do hereby declare under penalty of perjury that I do not have copies of the required CSBG documentation. State the reason you cannot provide all required documentation. Examples (Natural Disaster, Stranded, fleeing abusive home)
Reason for inability to provide required documents:
Should be Empty:

Self-Declaration for zero income or missing required documentation.