incomeverif2006 Sample Business Form

2006 INCOME VERIFICATION FORM ALL INFORMATION IS KEPT CONFIDENTIAL CLIENT NAME _____________________________________________________________ ADDRESS__________________________________________________________________ Each participant in this program is required by the Department of Housing and Urban Development and the City of Cleveland, Department of Community Development, to provide their income level to establish eligibility to participate in this federally funded program, to verify race/ethnicity, and female-head of household status, for data collection purposes only. From the income levels listed below, please circle the number of persons in your household and the income level that matches your household size. Check the appropriate boxes for race, ethnicity and when applicable, female-headed household. Sign your name to verify that the information you supplied to the Agency is true. Check if Female-Headed Household Number of Persons In Household (Circle one) 1 2 3 4 5 6 7 8+ Very Low Income (0 to 30% of MFI) 12,900 or less 14,700 or less 16,550 or less 18,400 or less 19,850 or less 21,350 or less 22,800 or less 24,300 or less Low Income (31 to 50% of MFI) (Circle one) 12,901-21,500 14,701-24,550 16,551-27,650 18,401-30,700 19,851-33,150 21,351-35,600 22,801-38,050 23,301-40,500 Moderate Income (51 to 80% of MFI) 21,501-34,350 24,551-39,300 27,651-44,200 30,701-49,100 33,151-53,050 35,601-56,950 38,051-60,900 40,501-64,800 White Black-African American RACE (Check one) Asian & White American Indian-Alaskan Native Asian Asian & White American Indian-Alaskan Native & Black ETHNICITY Check if of Hispanic or Latino Origin Black-African American & White Native Hawaiian-Other Pacific Islander Other Multi-Racial Participant’s Signature Date TO BE COMPLETED BY AGENCY Census Tract Number Incomeverif2006.doc