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Apply for Head Start - New Center Location in Lodi 

Applications and additional pages

Self-Declaration of Income Form

Self-Declaration of Income Form

Online Application - Self-Declaration of Income

Complete the information below only if you have no other way to document your income. Please complete all applicable sections. If not all sections are complete there may be a delay in processing your application.

Monetary Support section:

If you are receiving help paying your bills and / or expenses from a non-household member, please list their name(s) and phone number(s) below, including a signed statement from that person(s). The statement should note how much money is provided, how often, and if the money is given to you or paid directly to your creditors. If more than one person is paying expenses, have him/her submit a separate signed statement as well and provide their name(s), phone number(s) and address(es) below.

Person 1
First Name
Last Name
Country
Address Line 1
Address Line 2
City
State/Province
Postal Code
Person 2
First Name
Last Name
Country
Address Line 1
Address Line 2
City
State/Province
Postal Code
Person 3
Country
Address Line 1
Address Line 2
City
State/Province
Postal Code
Explain how expenses are paid
Write N/A if it does not apply
Write N/A if it does not apply
How is car payment / insurance paid?
Write N/A if it does not apply
How is cable/internet bill paid?
Write N/A if it does not apply
How are personal expenses paid?
Write N/A if it does not apply
How are bulk fuels paid for?
Write N/A if it does not apply
How are other expenses paid?
Does your household recieve any of the following?
Food Stamps
If applicable
Rental Assistance (i.e. Section 8, HUD, Metropolitan Housing)
If applicable
Utility Allowance (HUD)
If applicable
Is Utility allowance paid directly to the utility companies?
If applicable
Income Comments Section
I declare under penalty of perjury that the information on this worksheet is true and correct
Month
/
Day
/
Year
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