Appendix C

SELF-DECLARATION OF INCOME REPORT / FY2020-21

(Effective June 1, 2021)

Federal regulations require we obtain this information to document assistance is being provided to low and moderate-income households. The Participant/Guardian should complete this form indicating all persons residing within their household, regardless of whether or not they are related. The Grantee should retain this form for monthly reporting requirements as well as for on-site monitoring visits.

INFORMATION PROVIDED ON THIS FORM IS KEPT CONFIDENTIAL AND IS NOT SHARED WITH ANY OTHER AGENCIES

PLEASE NOTE: ALL FOUR SECTIONS OF THIS FORM MUST BE COMPLETED TO RECEIVE REIMBURSEMSENT

Participant Information

Full Name

Participant Status

IndividualFamily

Address

City

State / Zip Code

Ethnicity

Hispanic or LatinoNot Hispanic or Latino

Race

Household Information

How many members live in your household? (Family and non- family)

Please Select corresponding income level.
Note: Does not need to be on same row as number of household size ~
should be accurate yearly household income

Contact Information