How do I fill out the Asset Income Self-Certification form?

The purpose of this form is to provide detail on assets that any member in the household has access to. This form must be filled out entirely and all values must be filled out.
If the value does not apply (you do not have that asset), you must mark it as $0. Do not use ‘N/A’ or cross it out or leave it blank as we will not accept the form.

As you can see from the example below, you must fill out the following:

• As you can see from the example below, you must fill out the following:
• Applicant/Participant name (full name of the Head of Household).
• Applicant/participant address including street, city, state and zip code.
• You must Select yes or no if the total amount of combined assets values more than $50,000. If you do have assets valued more than this number, you will need to provide verification of all assets in your household.
• You must go through each asset and mark a value. If you do not have that asset, you must mark it as $0. You must total the assets at the end, even if all of the values are $0.
• The head of household must sign and date the form.