Zero Income Verification Form

July 21, 2011

A zero income verification form is a document filled by an individual who has no income or no source of income in order to apply for assistance to meet his expenses. The form lists the details of expenses incurred by the individual though he has no income.

Sample Zero Income Verification Form:



Personal details:

Name: First name ________ Middle name ___________ Surname___________

Address: Street address _________   City name ___________ State ___________

Postal code ____________

Date of birth: ______________

Gender: _____________

Home contact number: __________

Application details:

Date from which income is not received ____________

Expected date till which the individual will not receive any income and the reason for the same: _________________

Total amount of daily/monthly expenses incurred: __________________

Reason for applying for financial assistance: ______________

I assure that the above mentioned information is true and correct. I also understand that it is my responsibility to record and report any change in household income within ten business days


Signature of applicant

Date: ____________________

Name of Witness:  ________________

______________________                                                Date: ____________

Signature of witness


Download Zero Income Verification Form in Word Format

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