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THIS INFORMATION IS STRICTLY CONFIDENTIAL AND WILL BE USED ONLY
TO DETERMINE IF YOUR COMMUNITY IS ELIGIBLE FOR GRANT MONEY
TOTAL HOUSEHOLD INCOME - PLEASE CHECK BELOW
2016 COMMUNITY DEVELOPMENT BLOCK GRANT FEDERAL INCOME LIMITS:
_____ Up to 12,100 _____ Up to 49,700 _____ Up to 32,200 _____ Up to 53,400 _____ Up to 36,800
_____ Up to 57,050 _____ Up to 41,400 _____ Up to 60,750 _____ Up to 46,000 _____ Over 60,750
SOURCE OF INCOME - PLEASE CHECK BELOW
MARITAL STATUS: _____Married _____Single _____Widowed _____Single Parent
FAMILY MINORITY STATUS: ______White _____Black _____American Indian _____Alaskan Native _____Asian _____Hispanic
Is Head of Household Female? _____YES _____ NO
Is Head of Household Permanently Disabled? _____ YES _____ NO
Do you own your Home? _____YES _____ NO
If NO, Name of Owner/Landlord:____________________________________
1. Gross wages before deductions of all adult members of the households.
2. The Net income from operation of a business or profession or from rental of real or personal property.
3. Interest and dividends.
4. Social Security and pensions.
5. Unemployment Compensation, Disability Compensation, Workmen's Compensation.
6. Public Assistance.
Alimony and child support.
ANNUAL INCOME DOES NOT INCLUDE:
1. Income from dependent minors under age 18. Heads of households and spouses may never be considered minors.
2. Income of full-time students age 18 or older, who are not heads of households or spouses.
3. One-time additions to family assets such as inheritances, capital gains, settlement for personal or property losses.