STATEMENT OF FAMILY SIZE
I HEREBY CERTIFY, UNDER PENALTY OF PERJURY THAT I am unable to provide the acceptable
documentation to prove family size. Therefore, I state that my family consists of the following members,
including myself, and all related by blood, marriage, or decree of court as follows:
If a family member is over eighteen (18) in the household please state if they are working or not working.
RELATIONSHIP TO PLEASE STATE IF WORKING
I NAME OF FAMILY MEMBER
APPLICANT OR NOT WORKING
attest that the information stated above is true and accurate, and I understand that the above information, if
misrepresented, or incomplete, may be grounds for immediate termination, non-acceptance, and/or penalties
as specified by law.
Applicant Signature Date
Applicant Address City State, Zip Code
______________________________________________
Phone Number
Collaborating Witness Signature Date
Witness Address City State, Zip Code
______________________________________________
Phone Number
An equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. All voice telephone numbers
on this document may be reached by persons using TDD/TTY equipment via the Florida Relay Service at 711. Family Size, Revised 11/28/2024.
