San Juan Unified School District

EARLY CHILDHOOD EDUCATION

Part Day State Preschool

CERTIFICATION OF EMPLOYMENT / INCOME INFORMATION

Parent: ______________________________________
Child(ren): ___________________________________
All parents must sign
I, _____________________________, give my employer permission to release employment
PLEASE PRINT CLEARLY

information to SJUSD ECE programs.

Parent Signature: _____________________________

Mark all that apply

I certify that I am employed:

Name of Company: ____________________________________________
Address: ____________________________________________________
City: ___________________________State: _____ Zip Code: _________
Phone: (

I certify that:

I am unemployed

I am incapacitated

I am currently in school

Other: __________________________________

I certify that I receive or pay Child Support and/or Alimony:

Child support: -Receive;

-Pay;

Amount $___________

-Receive;

-Pay;

Amount $___________

Alimony:

) _________________ Usual Business Hours: ____________

I certify that I receive other income:

Source of income: _____________________________________________

I certify that I have no income and do not receive cash aid, unemployment,
disability, school loans/grants, money from family members or any other person.
Other ______________________________________________________________
____________________________________________________________________

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and
correct and of my own personal knowledge, and that if called upon to testify, I would be competent to
testify thereto.

Signed

Date
(Printed)

2/13/12 BW