Resident: Zero or Low-Income Verification Form
Arkansas County Housing Authority
P 870.946.2622
Monday - Friday • 8:00 am - 4:30 pm
105 W. 4th Street • P.O. Box 447 • DeWitt AR, 72042
[email protected]
Zero or Low-Income Verification Form
Why You're Completing This Form
You are filling out this form because you reported little or no income. We must confirm how you and your household pay for daily living expenses, such as food, transportation, and utilities.
This helps us:
- Make sure your information is complete and correct
- Count all types of income, including help from others (cash or items)
- Keep your rent and assistance accurate
Who Must Complete This Form
- Head of Household (you)
- Anyone giving you money or help (family, friends, church, or organization) must also fill out the Statement of Financial Assistance at the end.
This form is required:
- When you first apply
- Each year during recertification
- Every 6 months, while reporting no income
Important Notice
It is against federal law to give false or incomplete information. Doing so can result in:
- Losing your housing or rental assistance
- Having to pay back rent or benefits
- Being banned from future assistance
- Fines or criminal charges
Household Expense Review
Please answer all questions. If someone helps you pay for something, list their name, address, phone number, and how much they help.
Fields marked with * must be completed, or the form will not submit.
