Income Statement Leave this field blank 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 and additional information as their proof of income. Name of Child Date of Birth Name of Parent/ Guardian Please explain in DETAIL how you are supporting your family without an income by addressing the following expenses: rent/housing, bills, food, clothes, etc. Include an explanation of unearned income (if applicable) such as savings, monetary help from family/friends/others, child support, unemployment, etc. 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
