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Form HS-1042-A — Application for Household Support Benefits

SECTION I — APPLICANT ATTESTATION AND CERTIFICATION OF ELIGIBILITY (COMPLETE IN FULL; INCOMPLETE SUBMISSIONS WILL BE ADMINISTRATIVELY CLOSED WITHOUT FURTHER NOTICE)

Pursuant to statutory authority under Title 14, Subchapter 9(b)(2), the undersigned applicant hereby certifies that the aggregate gross income received by all members of the household during the preceding taxable period, inclusive of wages, salaries, benefits, distributions, and other forms of remuneration, has been accurately disclosed herein, and further acknowledges that any material misrepresentation may result in disqualification and referral pursuant to applicable enforcement provisions.

Indicate below, in the shaded boxes only, the HH composition as of the DOA, including all dependents claimed for purposes of the FPL determination and any non-custodial contributors (see Attachment 4, p. 11).

NOTE (red text): Failure to submit Attachment 4 within 10 business days will result in denial. Session expires after 15 minutes.

If you require an accommodation, refer to page 14, paragraph 9.3.

(Fictional sample, written to contain the barriers found in real public-benefit forms.)