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FORM P

705 Revised
04-10-2018

Declaration of Income

(DECLARACION DE INGRESOS)

Applicant Name (Nombre del Solicitante) Applicant Last Name (Apellido) Suffix (Sufijo)
Address (Dirección) City (Ciudad) Zip Code (Código Postal)

State the gross income for household members, 18 years and older, who have no documentation of the
income received in the 30 day period prior to the date of application for assistance: (Declarar el ingreso

recibido por los miembros de su hogar, que tienen 18 años de edad ó mas, y que no tienen

documentación de ingresos por los 30 dias antes del aplicar para asistencia)

Name (Nombre) Gross Income Received (Ingreso Bruto
Name (Nombre) Recibido)
Name (Nombre)
Name (Nombre) Gross Income Received (Ingreso Bruto
Recibido)
Gross Income Received (Ingreso Bruto
Recibido)
Gross Income Received (Ingreso Bruto
Recibido)

My household has no documented proof of income due to the following situation (Mi hogar no tiene
prueba para documentar los ingresos por medio de tal razones):

I certify that the above information is true and correct to the best of my knowledge and belief. (Yo
certifico que la información proveida de los ingresos es verdadera y correcta según mi saber y creencia.)

I understand that the information will be verified to the extent possible; and that I may be subject to
prosecution for providing false or fraudulent information. (Comprendo que la información será verificada
hasta donde sea posible y que puedo ser enjuiciado por haber proveido información falsa ó fraudulenta.)

(Applicant Signature/Firma del Solicitante) (Date/Fecha)

With respect to the use of the Declaration of Income Statement form that allows clients to declare their income without providing proof, CSNT establishes the following policy. DIS
forms will only be used when all efforts have been made to secure documentation of household income and when there are serious extenuating circumstances that justify the use of
the form. Except in situations where documents may have been destroyed by a disaster situation, such as fire, flood, etc., no more than one DIS form shall be used per household

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