The following questions asking about your ethnicity and race are being asked for statistical purposes to make sure that we are giving fair and equal treatment to everyone. Your answers are voluntary and will have no effect on your senior services.
I certify that the information I have provided for my eligibility determination is correct, to the best of my knowledge.
I am providing this affidavit to verify my income
Income that meets the above listed criteria is 185% or less than the Federal Poverty Guidelines.