Marital Separation Status Affidavit

Name(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Spouse's Name(Required)

First Last

Our housing commission provides affordable housing under Section 42 of the Internal Revenue Code. Households applying for occupancy are required to disclose their marital status and future intentions for purposes of determining income eligibility.

Who should complete this form: If you are age 18 or older or an emancipated minor and you are currently separated from your spouse, this form must be completed.

The US Government requires the following:
- All questions must be answered YES, NO or,
- If a question does not apply, put N/A.
- If uncertain, use best available information
- Use of “White out” and pencil is prohibited.
- If information must be changed, strike through & initial change.
- Signature and date of person completing this form is required.

Choose and complete the appropriate numbered statement below:(Required)

I am currently legally separated from my spouse. (A copy of legal separation agreement must be attached.)

I am currently, but not legally, separated from my spouse. I began the legal process on and I anticipate this separation to be permanent

I am currently, but not legally, separated from my spouse and I have not begun the legal process

What day did you begin the legal process?(Required)

For what reason(s) have you not begun the legal process?(Required)

Choose and complete the following appropriate statement:(Required)

I am currently receiving or anticipate receiving $_______________ per _______________(frequency) from my spouse during the next 12 months for the purpose of ________________________________________.

I am not currently and do not anticipate receiving any compensation from my spouse during the 12 months

Fill in the blanks from your previous selection

I am currently receiving or anticipate receiving(Required)

Amount of Money

Per(Required)

Frequency

For the purpose of(Required)

For the following reason(s)

I am not currently and do not anticipate receiving any compensation from my spouse during the 12 months for the following reason(s)(Required)

Marital Separation Status Affidavit