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:Household Members with No Income Add RemoveI understand that the HES-IE program may request supporting documentation regarding my income. 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.Affidavit Acknowledgement I understand and agree to these terms. No Income Affidavit SignatureNo Income Affidavit Signature MM slash DD slash YYYY
