Affidavit

AJFC Community Action Agency, Inc.

To be completed and signed by the applicant and / or household member.

Complete the fields, then print for required signatures and notarization. Entries are not submitted to AJFC or saved by this worksheet. Print or save a PDF before leaving or refreshing this page.

1. Date of Application 2. Applicant’s Name

3. Name of Household Member

4. Relationship to Applicant Self Spouse Authorized Representative Other

5. Household Member Social Security Number
________________________________________

For privacy, enter the Social Security number on the printed form.

6. Household Member Birthdate

Please check one Authorized Representative applying for services on behalf of the applicant Separation Zero-Income Household Unemployed Other Other explanation

Comments I, STATE THAT I

FOR THE PERIOD OF TO

I UNDERSTAND THAT I CAN BE PENALIZED BY FINES, IMPRISONMENT, AND/OR REIMBURSEMENT OF SERVICES FOR MAKING FALSE STATEMENTS.

Signature ______________________________________
Date ____________________

Signature of Authorized Rep. _____________________________
Date ____________________

Notary Signature _______________________________________
Date ____________________

Revised: December 2025

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