ZERO INCOME STATEMENT_1_

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					                             ZERO INCOME STATEMENT



      Date


      Last/First Name                                              Date of Birth


   1. I am signing this letter to declare that I currently do not have any income from any
      source. My financial support comes from (please describe):




      Did you file a Federal Income Tax Return in the past 2 years? (circle one)

      No      Yes

      If yes, submit a copy of your most recent Federal Income Tax Return.

   2. I agree to notify the above provider about changes in my income within 30 days of
      the change.

   3. I agree to apply for assistance from the Michigan Works program and from the State
      of Michigan Department of Human Services (DHS) as soon as possible.

   4. I agree to give a copy of my determination letter from the DHS to the provider for my
      file as soon as possible after I receive it.

   5. I understand that by completing, signing, and dating this form, I declare I have no
      household income and that the information I am providing is correct. I understand
      that providing false information may result in denial of services.




Signature

				
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Description: Profit and loss account, also known as income statement, is the reflection of a certain accounting period operating results and the distribution of financial statements is a period of time the financial records of company performance, reflecting the time of the sales revenue, cost of sales , operating expenses and tax status, report the results for the company to achieve profits or losses of the formation.