Exhibit E Arizona Department of Economic Security

Rapid Rehousing (RRH) Income Verification Calculation Worksheet

DECLARATION OF NO INCOME

Must complete both pages of this ‘Declaration of No Income’ document.

(HMIS ID)

I understand sources of income include, but are not limited to:

· Unemployment benefits

· Employment

· TANF (Temporary Assistance to Needy Families)

· Social Security benefits

· S.S.I (Supplemental Security Income) / S.S.D.I. (Social Security Disability Insurance)

· General Assistance (CAAP, PAES, CALM, SSIP, GA)

· V.A. Pension

· Retirement Benefits

· Disability Benefits

· Spousal Support

· Child Support

· Income From Assets

· School Grants

· Family Support (parent, children, etc.)

· Interest From Savings Account

· Self-employment (including child care, housekeeping, work from home, contracted, etc.)

· Any other interest received I further understand that should I become gainfully employed or begin receiving income from any source, it must be reported to the Program immediately.

I sign this declaration under penalty of perjury and with full knowledge of the repercussions of willful falsification.

Section 1001 of Title 18 of the US Code makes it a criminal offense to make willful false statements or misrepresentations to any department or agency of the United States as to matters within its jurisdiction.

Client HMIS ID Signature:

Date:

Signed:

(Signature of agency representative)

DECLARATION OF NO INCOME (CONTINUED)

Please answer the following questions to determine that you are indeed, without income ($0.00). If you are without income, you must complete and submit both pages of this ‘Declaration of No Income’ document.

If yes, who?

How do you pay for food?

If yes, how?

If yes, how?

How do you buy gas?

How do you make payments?

How do you pay the bill?

If you answered ‘yes’ to ANY of the above questions, please obtain WRITTEN VERIFICATION proving that the resource(s) used to pay the item(s) is/are not from your own income. The written verification needs to be provided by the source providing the income to support client.

RRH Income Verification Worksheet for Youth & Families

HMIS/ DV ID #:

DATE:

This worksheet is to be utilized by DES Youth & Families Rapid Rehousing Program providers. The income calculator can be accessed through this link: https://www.hudexchange.info/incomecalculator/ . If the Subrecipient uses the CPD Income Calculator, the income calculation must be printed and added to the client file. Additional information and training webinar on how to use the CPD Income Calculator can be found here:

https://www.hudexchange.info/trainings/courses/using-the-income-calculator-to-determine-annual-income webinar1/

· Income certification must be completed after financial assistance has been provided for one year.

· Household income must be at or below 50% of AMI. Under the DES Youth & Families Rapid Rehousing Program, income eligibility is based on the HUD income limits in effect at the time of income verification. Income eligibility is not based on HUD income limits that correspond with the grant year under which the funds were awarded. Income limits can be found here: https://www.huduser.gov/portal/datasets/il.html The information used to populate this worksheet should come directly from the Third Party Documentation of Income and/or the Client’s Self Certification of Income Form.

Income

Household Member

Total Income $

Total Income from Assets $

Total Annual Income (Line 1 plus Line 2) $

50% of AMI for your area $

Household income is ineligible if line 3 is greater than line 4

Verified by:

Date: