City Of Plano Cdbg Eligibility Certification Form (Page 4 of 4) in pdf

INCOME VERIFICATION DATA

The assistance you receive is determined in part by the size of your family and your income. Failure to disclose any

income or assets is a criminal offense. All income and assets will require verification before eligibility will be

granted. Income includes all money coming into the family from all persons over 18 years old. Self-employment

wages, TANF, alimony, Social Security benefits, pensions, child support, and regular gifts of money from friends,

family or a church must be disclosed. Money earned from providing services, and interest from bank accounts or

investments must be disclosed.

I hereby certify that the total gross income (before deductions) of ALL family members is

$__________________ per month. This includes all sources of income received by the household. I

further certify that I cannot provide written proof of income because I am unemployed, am normally paid in

cash, or other reason.

BY MY SIGNATURE, I ACKNOWLEDGE THAT ALL INFORMATION I HAVE PROVIDED IS TRUE AND

CORRECT TO THE BEST OF MY KNOWLEDGE.

I AM AWARE THAT MAKING A FALSE

STATEMENT TO OBTAIN BENEFITS TO WHICH I AM NOT ENTITLED IS A CRIME AND MAY

SUBJECT ME TO BOTH CIVIL AND CRIMINAL PENALTIES.

Signature of Applicant

Date

FOR AGENCY USE ONLY:

A copy of Client and/or Head of Family ID or SS# Must be placed in the Client file

Agency notes regarding household’s income (i.e. reasons as to why proof of income is not available or

any other income-related information regarding the household):

Results:

This family’s total annual income is $_______________________, which is WITHIN or EXCEEDS (circle

one) CDBG income guidelines.

I have reviewed this application and find it complete. I am aware that making false statements is a

breach of contract and may result in civil or criminal penalties to either myself and/or this organization.

The above client is APPROVED or DENIED CDBG assistance. Reason for denial:

______________________________________

____________________________

Staff Signature

Date

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

Effective 10/01/2013

City Of Plano Cdbg Eligibility Certification Form Page 4