Self Declaration Income Affidavit - Download as PDF by diz19964


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									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:____________

1- CAA Forms – Self-Declaration Income - English

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