Microenterprise Program Self-Certification Of Income printable pdf download

Microenterprise Program SELF-CERTIFICATION of Income for

☐ City of / ☐Town of / ☐ County of

_____________________ CDBG Funded Activity

☐ Technical Assistance

☐ Support Services

Program Activity:

Page 1 to be filled out by Participant

Part I: Confidential Participant / Beneficiary HUD Demographic Data

(This section is voluntary.)

☐ Not Hispanic

☐ Hispanic

Ethnicity (Select One)

Race

(Select One)

☐ White

☐ Am. Indian/Alaskan Nat. & White

☐ Black/African American

☐ Asian & White

☐ Asian

☐ Black/African American & White

☐ American Indian/Alaskan Native

☐ Am. Indian/Alaskan & Black/African

☐ Nat. Hawaiian/Other Pacific Isl.

☐ Other Multi-Racial

Other Demographic Data (Select each that Applies)

☐ Female Head of Household

☐ Single / Non Elderly

☐ Participant Disable

☐ Related/Single Parent

☐ Veteran

☐ Related/Two Parent

☐ Elderly

☐ Other (_________________________)

Part II: Confidential Participant / Beneficiary Income Certification

(Must be completed and signed before microenterprise services are provided.)

1) Number of Employees & Owners:

The total number of employee(s) is: _____. The total number of Owner(s) is: _____. Combined

Employee(s) and Owner(s) =_______.

2) Number of Family Members & Gross Income:

My total family size consists of ____________ members, and the total gross annual income* for all

adult members is $___________________________.

*Gross annual income must include all sources of income (wages, child support, SSI, unemployment, pension, income

from assets, etc., but does not include the income of live-in aids, per 24 CFR 5.403).

I certify that the information given on this form is true and accurate to the best of my knowledge.

I am

aware that there are penalties for willfully and knowingly giving false information on an application for

Federal or State funds, which may include immediate repayment of all Federal or State funds received

and/or prosecution under the law. I understand that the information on this form is subject to verification by

state and federal personnel as part of compliance monitoring.

___

__________________

Participant / Beneficiary Signature:

Date:

_______________________________________________

Participant / Beneficiary Name (print):

Participant Physical Home Address: _____________________________________,City_____________

Page 1 of 2

HCD Revised: August, 2015

Microenterprise Program Self-Certification Of Income

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