Affidavit for Household with No Income:
I affirm that no adult over
the age of 18 years, listed below, who lives in my household, has had any income in the four
weeks prior to the date this affidavit is signed below. This means no adult in my household
and is listed below has received income from employment, a pension, unemployment or
worker's compensation, cash assistance from the Connecticut Department of Social Services
(Temporary Family Assistance, State Supplement or the State Administered General
Assistance program), benefits from the Social Security or Veteran's Administration, child
support, alimony, interest, or any other income source.
The following people live in my household and have no income:
I understand that the HES-IE program may request supporting documentation regarding my
I affirm that the information indicated on this form is accurate. I understand that if the
information is not correct, I may be charged for the energy efficiency services I am provided
by the HES-IE program.