ZERO INCOME CERTIFICATION
Virginia Rent Relief Program
I, , have applied for emergency rental assistance through the Virginia
Rent Relief Program (RRP). Program regulations require verification of all income from participating households.
Income includes but is not limited to:
1) The full amount, before any payroll deductions, of wages and salaries, overtime pay, commissions,
fees, tips and bonuses, and other compensation for personal services;
2) The net income from operation of a business or profession. Expenditures for business expansion or
amortization of capital indebtedness shall not be used as deductions in determining net income. An
allowance for depreciation of assets used in a business or profession may be deducted, based on straight
line depreciation, as provided in Internal Revenue Service regulations. Any withdrawal of cash or assets
from the operation of a business or profession will be included in income, except to the extent the withdrawal
is reimbursement of cash or assets invested in the operation by the family;
3) Interest, dividends, and other net income of any kind from real or personal property. Expenditures for
amortization of capital indebtedness shall not be used as deductions in determining net income. An
allowance for depreciation is permitted only as authorized in paragraph (2) above. Any withdrawal of cash or
assets from an investment will be included in income, except to the extent the withdrawal is reimbursement
of cash or assets invested by the family. Where the family has net family assets in excess of $5,000, annual
income shall include the greater of the actual income derived from all net family assets or a percentage of
the value of such assets based on the current passbook savings rate, as determined by HUD;
4) The full amount of periodic amounts received from social security, annuities, insurance policies, retirement
funds, pensions, disability or death benefits, and other similar types of periodic receipts, including a lump-
sum amount or prospective monthly amounts for the delayed start of a **periodic amount (e.g., Black
Lung
Sick benefits, Veterans Disability, Dependent Indemnity Compensation, payments to the widow of a
serviceman killed in action). See paragraph (13) under Income Exclusions for an exception to this
paragraph;**
5) Payments in lieu of earnings, such as unemployment, disability compensation, worker's
compensation, and severance pay, except as provided in paragraph (3) under Income Exclusions;
6) Public Economic Assistance Programs
a) Public assistance received by the family from the Temporary Assistance for Needy Families
(TANF) program is counted as income, but not assistance received from the Women’s, Infant,
and Children (WIC) program, the Low Income Home Energy Assistance Program (LIHEAP), or
the Supplemental Nutrition Assistance Program (SNAP) is not counted as income.
b) If the assistance payment includes an amount specifically designated for shelter and utilities that
is subject to adjustment by the assistance agency in accordance with the actual cost of shelte
r
and
utilities, the amount of assistance income to be included as income shall consist of:
(i) The amount of the allowance or grant exclusive of the amount specifically designated for
shelter or utilities; plus
(ii) The maximum amount that the assistance agency could in fact allow the family for shelter
and utilities. If the family’s assistance is ratably reduced from the standard of need by
applying a percentage, the amount calculated under this paragraph shall be the amount
resulting from one application of the percentage.
7) Periodic and determinable allowances, such as alimony and child support payments, and regular
contributions or gifts received from organizations or from persons not residing in the dwelling; and
8) All regular pay, special pay, and allowances of a member of the Armed Forces, except as provided in
paragraph (7) under Income Exclusions.
More
information, including a list of Income Exclusions can be found at:
https://www.hud.gov/sites/documents/DOC_35699.PDF
I understand that any misrepresentation of information or failure to disclose information requested on this
form may disqualify me from participation in RRP, and may be grounds for termination of assistance.
WARNING: It is unlawful to provide false information to the government when applying for federal public
benefit programs per the Program Fraud Civil Remedies Act of 1986, 31 U.S.C. §§ 3801-3812.
I certify that the above information is true and correct.
Signature: Date:
NOTE: If other adult member(s) of the household do not have income, the primary applicant must
certify that those members do not have any income by providing their names and initialing below.
________________________________________________ ______________________
Name of adult household member with no income #2 Primary Applicant’s Initials
________________________________________________ ______________________
Name of adult household member with no income #3 Primary Applicant’s Initials
________________________________________________ ______________________
Name of adult household member with no income #4 Primary Applicant’s Initials
________________________________________________ ______________________
Name of adult household member with no income #5 Primary Applicant’s Initials
I certify that:
I have no income as defined above
Yes / No
Other adult household member(s) have no income as defined above
Yes / No
click to sign
signature
click to edit