Self-Employment Affidavit

Please write your full name (first & last)
Remember to include unit/apartment # if applicable
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. 
Please write the name of the company/organization/business which you are self-employed through

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