Self-Employment Affidavit

Name: *

Please write your full name (first & last)

Address: *

Remember to include unit/apartment # if applicable

Authorization

Federal Regulations require us to verify the employment income of all members of the household applying for participation in the Burlington Lead Program which we operate. We ask your cooperation in supplying this information. This information will be used only to determine the eligibility status and level of benefit of the household.

I certify that I am self-employed through: *

Please write the name of the company/organization/business which you are self-employed through

I estimate that my net income for the next 12 months will be: * $

To third-party verify your self-employment income, we require a copy of your most recent income tax return (Form 1040). Please email this form to blp@burlingtonvt.gov or send to: 149 Church St. Room 32 Burlington, VT 05401

I agree to provide a copy of my most recent income tax return (Form 1040) *

Yes

No (if you answer 'No', we will not be able to verify your income through a Self-Employment Affidavit)

Signature

Please write your signature below with your cursor

Signer Name *

Self-Employment Affidavit

Contact BLP

149 Church St. Room 32

Burlington, VT 05401