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Section 3 Employee Household Income Certification Form 5 - New Jersey Economic Development Authority, Office Of Recovery

EXHIBIT 5

SECTION 3 EMPLOYEE HOUSEHOLD INCOME CERTIFICATION FORM 5

NEW JERSEY ECONOMIC DEVELOPMENT AUTHORITY

Office of Recovery

P.O. Box 990 - Trenton, NJ 08625-0990

CDBG-DR ECONOMIC REVITALIZATION

LOW / MODERATE INCOME (LMI) AND RESIDENCY EMPLOYMENT OPPORTUNITY

This worksheet must be completed and returned to the General Contractor and/or the NJEDA.

Form available at: action

Eligibility for Preference

Any individual who is seeking to be certified as a Section 3 resident, and who is not a public housing resident, or not a

federally assistant housing program, or not a recipient public housing assistance program shall attest to their total current gross

annual household income, and provide the name and date of birth of each household member. All additional household

income earned by household members, excluding children under 18, and/or provided through public or private assistance,

child support, bank or investment earnings must be included, where indicated below.

(Individual's Full Name) DO SOLEMLY SWEAR THAT THE

INFORMATION PROVIDED BELOW IS TRUE.

*Number of family members who live in my household:

. (See Section 3 Waiver blow)

My total current gross annual household income is:

The source(s) of my total annual household income is/are:

Other Adult

Section 3

Spouse

Members age

Employee

(if applicable)

18 & over

(if applicable)

Gross

Earnings

TANF

Child

Support

Bank

Income

Other

Income

List

Print Name:

Signature:

Date:

Section 3 Employee Household Income Certification Form 5 - New Jersey Economic Development Authority, Office Of Recovery