U.S. Department of Housing and Urban Development Community Planning and Development
Community Development Block Grant (CDBG)
Self Certification of Annual Income by Beneficiary
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Printed On: *
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Effective Date:
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Instructions: This is a written statement from the beneficiary documenting the definition used to determine "Annual (Gross) Income", the number of beneficiary members in the family or household (as applicable based on the activity), and the relevant characteristics of each member for the purposes of income determination. To complete this statement, select the definition of income used, fill in the blank fields below, and check only the boxes that apply to each member. Adult beneficiary members must then sign this statement to certify that the information is complete and accurate, and that source documentation will be provided upon request. *
Definition of Income: *
Beneficiary Information (Last Name): *
Beneficiary ID (if applicable):
Member Information 1 (First Name)
Member Information 1 ID (if applicable)
HH=Head of Household, CH=Co-Head of Household, DIS= Person with disabilities, 62+= Person 62 years of age or older, S>18= Full time student age 18 or over, <18= Child under the age of 18 years, <15= Minor under the age of 15 years. *
Member Information 1 Status
Clear selection
Member Information 2 (First Name)
Member Information 2 ID (if applicable)
Member Information 2 Status
Clear selection
Member Information 3 (First Name)
Member Information 3 ID (if applicable)
Member Information 3 Status
Clear selection
Member Information 4 (First Name)
Member Information 4 ID (if applicable)
Member Information 4 Status
Clear selection
Member Information 5 (First Name)
Member Information 5 ID (if applicable)
Member Information 5 Status
Clear selection
Member Information 6 (First Name)
Member Information 6 ID (if applicable)
Member Information 6 Status
Clear selection
Member Information 7 (First Name)
Member Information 7 ID (if applicable)
Member Information 7 Status
Clear selection
Member Information 8 (First Name)
Member Information 8 ID (if applicable)
Member Information 8 Status
Clear selection
Member Information 9 (First Name)
Member Information 9 ID (if applicable)
Member Information 9 Status
Clear selection
Member Information 10 (First Name)
Member Information 10 ID (if applicable)
Member Information 10 Status
Clear selection
Member Information 11 (First Name)
Member Information 11 ID (if applicable)
Member Information 11 Status
Clear selection
Member Information 12 (First Name)
Member Information 12 ID (if applicable)
Member Information 12 Status
Clear selection
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