Pasadena, TX · Harris County
Self-Certification of Income
This form records household income or no income for an Emergency Solutions Grants applicant when third-party verification cannot be obtained.
What this form is
The form documents an applicant’s income or lack of income for Emergency Solutions Grants and should be used only as a last resort when third-party documentation cannot be obtained. It is required for Homelessness Prevention assistance at program entry and every three months, and for Rapid Rehousing at annual re-evaluation. It asks for the applicant’s name, income sources, amounts and frequency, and signatures and dates from the client and intake staff.
Who needs it
Adult household members age 18 or older provide this certification when applying for the specified Emergency Solutions Grants assistance and third-party documentation cannot be obtained.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This document has no notary block; the client signs and dates the certification under penalty of perjury, and intake staff also sign and date the form.
How to submit this form
- 1
Download the Form
Download the Self-Certification of Income form for Emergency Solutions Grants.
- 2
Complete the Income Section
Enter the applicant’s name and complete only the section that applies: income sources, amounts and frequency, or no income.
- 3
Document Verification Attempts
Intake staff record attempts to obtain third-party verification, including the date, contact, type of attempt and outcome.
- 4
Sign and Submit
The client and intake staff sign and date the form. Submit it to the city department named on the form.
Frequently asked questions
- Who completes the Self-Certification of Income?
- The form is required from all adult household members age 18 or older. It is used for specified Emergency Solutions Grants assistance when third-party income documentation cannot be obtained.
- When is this income form required?
- It is required for Homelessness Prevention assistance at program entry and every three months, and for Rapid Rehousing assistance at annual re-evaluation.
- Do I need a notary for the Self-Certification of Income?
- No. The form has no notary block. The client signs and dates the certification under penalty of perjury, and intake staff also sign and date it.
- How do I submit the Self-Certification of Income?
- Submit it to the city department named on the form; check the city website for current contact details.
Need something notarized?
This Self-Certification of Income doesn’t need a notary — but Texas residents can notarize other documents online with a commissioned online notary.