Western Worcester Income Verification

Western Worcester

For business owners residing Athol, Hardwick, Hubbardston, New Braintree, Petersham, Phillipston, Royalston, Warren, West Warren
Community Development Block Grant Program (CDBG)

Small Business Assistance Microenterprise Verification Form
Please be assured that this information will remain confidential and will be used only to meet the record keeping requirements of the U.S. Department of Housing and Urban Development, which is providing the CDBG funds. As soon as you have completed the information listed below, please return it to the Quaboag Valley Community Development Corporation, 23 West Main St, Ware, MA 01082, Melissa @qvcdc.org. Thank you for your cooperation.
Owner Name

First Name Last Name
Owner Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Owner Phone Number
Please enter a valid phone number.
Please indicate the NUMBER OF PEOPLE in your family, including yourself:

ONE, $49,500 TWO, $56,600 THREE, $63,650 FOUR, $70,700 FIVE, $76,400,800 SIX, $82,050 SEVEN, $87,700 EIGHT, $93,700
Was your total household income during the last 12 months higher or lower than the amount below the number you circled? please choose one

HIGHER LOWER
We will ask you to provide documentation of your income via your latest tax return or quarterly tax.
Please provide your adjusted gross income from your most recent tax return (On your 1040: line 8b on 2019 or line 7 on 2018 Year)INCOME field. Year of return: YEAR If you are reporting income from a tax return that is more than a year old, we may request additional information.
I hereby certify that the information contained on this form is accurate and complete to the best of my knowledge, under penalty of law and verifiable by federal government representatives. NAME field.
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Date *

Month Day Year
Date
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