How do I fill out the Household Certification form?

The purpose of this form is to collect current household composition and income as well as record asset information and if there have been any changes to any of the above. There are two pages to this form and all must be returned filled out.

As you can see the example below, the highlighted sections must be filled out. This includes the following:

• The name of the head of household and phone number
• The full address of where the household lives
• The email of the head of household
• Household composition section: Who is in the household, their relationship to the head of household, what are their demographics (optional), social security numbers, and if they are a full time student or not.  
• Household Income section: what is the income of the household and for who, income amounts, and frequency of the payments. If there is no income, please mark this section as $0. Do NOT leave this section blank.
• Assets section: You must include any assets in the household. If there are no assets, mark this section as $0 or N/A.   
• Childcare expenses: If there are child care expenses, please fill out this section. 
• Child support expenses: If there are child support expenses, please fill out this section. 
• Medical expenses section: If there are medical expenses, please fill out this section. 
• Educational expenses section: If there are educational expenses, please fill out this section. 
• Language section: Please include the preferred language for the household and if you understand English. 
• The last item of the page is for the head of household to sign and date the form.