City Of Plano Cdbg Eligibility Certification Form printable pdf download

City Of Plano Cdbg Eligibility Certification Form

CITY OF PLANO CDBG ELIGIBILITY CERTIFICATION FORM

(FOR PUBLIC SERVICE ACTIVITIES, EXCLUDING RENT/UTILITY ASSISTANCE PROGRAMS)

1. Date: _____________________

2. Client/Member Name:

3. Head of Family Name: ______________________________________

4. Is the Head of Household:

MALE OR

FEMALE ? (Check correct gender)

5. Permanent Address of Client:

6. City, State, Zip:

7. Phone:

8. E-Mail Address:

9. Is the client Hispanic? ___ Yes ___ No (please note that a race must be selected below)

10. What is the client’s race? Please check all that apply.

___ White

___ Black/African American

___ Asian

___ American Indian/Alaskan Native

___ Native Hawaiian/Pacific Islander

___ Other

11. How many people are in the client’s family? _______________________________

DEFINITION OF A FAMILY: A family is defined as all persons living in the same household who are related

by blood, marriage, or adoption, including adult children who continue to live at home with their parent(s) and

a dependent child who is living outside of the home (e.g, students living in a dormitory). An individual living in

a housing unit that contains no other person(s) related to him/her is considered to be a one person family for

this purpose.

12. List the client and all other family members in the chart below:

RELATIONSHIP

SEX

NAME

TO CLIENT/MEMBER

AGE

(MALE OR FEMALE)

SELF

FOR ALL CDBG PUBLIC SERVICE ACTIVITIES, EXCLUDING RENT/UTILITY ASSISTANCE PROGRAMS.

Effective 10/01/2013

City Of Plano Cdbg Eligibility Certification Form