Income Statement Leave this field blank Name of Child Date of Birth Name of Parent/ Guardian Enrollment applications for Head Start eligibility must have proof of income attached to the application. Families who are currently unemployed, without an income, or self-employed can submit this form & additional information as their proof of income. Please explain in detail how you are supporting your family without an income by addressing the following expenses: rent/housing, food, clothes, etc. Include an explanation of unearned income (if applicable) such as savings, help from family/friends/others, child support, unemployment, ect. For self-employed individuals: please declare your gross weekly, monthly, or yearly earnings. Parent/ Guardian Signature: Start drawing Clear Done Start over Date of Signature: Send
