SELF-EMPLOYMENT DECLARATION

Verification ofincome from Employment

Dear Sir/Madam;
We are required to verify the incomes of all family members living in or applying for public housing or
Section 8 housing. We ask your cooperation by supplying the information requested below about the
referenced person. We will use any information you provide only to determine the family's eligibility
and rent, and pledge to keep the data in strict confidence.

We would greatly appreciate your prompt return of this letter. A self-addressed, stamped return envelope
is enclosed. Note that the person referenced has authorized your release of the information. If you haveany questions, please call


Salary,Base Pay Rate

$ Per Hr
Hrs/Month

Any other compensation not listed above? Please specify for commissions, bonuses, tips, etc.?