Bessemer CDBG Grant - Participant Reporting Form

Please use the paper U.S. Department of Housing & Urban Development Community Development Block Grant form to complete this online form. We need to have a signature of each individual completing the form on file.

Information is required for EACH individual & their household.

Complete this form when someone receives food for the FIRST time.

Keep paper forms for THREE YEARS in your records in case of monitoring visits.

Agency Reporting

Select your agency you are reporting for:

Personal Information

Name:

Date of Birth (if blank, put 0):

Street Address:

Apt/Unit #:

City:

Zip:

Total # Household Residents:

# Household Residents who identify as MALE:

# Household Residents who identify as FEMALE:

# Household Residents who identify as OTHER:

Race & Ethnicity

# Household Residents who identify as of HISPANIC origin:

# Household Residents who identify as of NOT HISPANIC origin:

What ethnicity are the residents of your household:

HUD Income Limits

What is your household income category?

Contact Information

107 Walter Davis Drive, Birmingham, AL 35209
Need Assistance Mon–Fri? Don't hesitate to call us at (205) 942-8911