Form 56 - Income Certification Form Categorical Projects
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1
2Form 56
Income Certification Form
Categorical Projects
SECTION I
Name of Grantee__________________________
Name of Beneficiary__________________________
Address_________________________________
Address____________________________________
City______________________ Zip Code______
City______________________ Zip Code_________
Phone____________Fax_________________
Phone ____________________
Contact Person ___________________________
Date _____________________
TO BENEFICIARY: The grantee associated with this project has received Federal funds to assist its
operations. A condition of receiving the funds is that family income information be collected from
each beneficiary. The information you provide will be kept CONFIDENTIAL.
SECTION II
Please complete the following information in order for the grantee to meet its requirement. The information
below is subject to verification by government officials.
(A)
(B)
(C)
How many
Family income levels
Was the TOTAL family income for the last twelve
persons are in
(12) months ABOVE or BELOW the family size
the applicant’s
for ____________________
indicated in column A? (Check the appropriate
family?
County
coumn below)
(Circle one.)
ABOVE
BELOW
1
$ ____________________
2
$ ____________________
3
$ ____________________
4
$ ____________________
5
$ ____________________
6
$ ____________________
7
$ ____________________
8+
$ ____________________
I, __________________________________, hereby certify that all the above information is correct and give the above-
Typed Name of Beneficiary
named organization permission to verify the information on this form.
___________________________________________
_______________________________
Signature of Beneficiary
Social Security Number
SECTION III
The following information is not required by law, but is needed for statistical purposes.
Please check the one of the following ethnic categories that applies to you:
____ Hispanic or Latino
____Not Hispanic or Latino
Please check all of the following categories that apply to you:
____White
____Asian
____Black or African American
____American Indian or Alaska Native
____Native Hawaiian or Other Pacific Islander
Please check all of the following categories that may apply to you:
____Elderly
____Handicapped
____Female Head of Household
Form 56 - I
Instructions for Completing the
Form 56 – Page 1
June 2007
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