Declaration of Income | Washington Early Childhood Network

DECLARATION OF INCOME FOR IRREGULAR EMPLOYMENT

This form must be completed by any adult household members who are employed intermittently, self- employed, or who, for whatever reason, do not have tax forms, W-2 forms, check stubs, or applicable Department of Children and Family Services printouts to verify their income.

I,, state that my income or support comes from:

Self-employment (provide most recent IRS Form 1099)
Parents/Family (attach a statement from person providing support)
Circle all that apply:

Seasonal employment Irregular employment Cash payments

Other

I certify that the above information which I have provided regarding my income is true and that any false statements or misrepresentation could affect the eligibility of my child to participate in a publicly-funded early childhood program.

submit

Washington Parish Early Childhood Network

Application

DECLARATION OF INCOME FOR IRREGULAR EMPLOYMENT

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