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Self Declaration Income Affidavit - Download as PDF

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Self Declaration Income Affidavit - Download as PDF Powered By Docstoc
					Applicant’s Name: _________________________
Address: _________________________________
City, State and Zip Code: ____________________
Phone Number: ____________________________


Dear Healthy Kids and Young Adults:

I am providing this affidavit as my self-declaration of income.
I have no other income verification available to me.

Type of income: ______________________
I earn $_________________ (gross amount):
          □   every week
          □   every two weeks
          □   twice a month
          □   monthly
          □   annually

I last received this amount on_______________.

If applicable: My employer’s name is _________________ and their phone number is
__________________.

I understand that this information is subject to verification by the State of California. I
certify that the information presented in this letter is true and correct to the best of my
knowledge and belief.


______________________________
Name of Income Earner

_______________________________
Signature of Income Earner

_______________________________                    HKYA Application No:____________
Date




1- CAA Forms – Self-Declaration Income - English

				
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Description: Self Declaration Income Affidavit document sample