2020 Income Affidavit
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
RACE/ETHNICITY: Check the category which you think best describes you household:
Not Hispanic
Hispanic
White
Black / African American (AA)
Asian
Native American
Hawaiian / Pacific Islander
Native American and White
Asian and White
AA and White
NA and AA
Other or Multi-Racial
Female-Headed Household? (Y/N)
Annual Household Income ($)?
Family Size
Certification
I understand that funding for this service comes from federal funds which require income eligibility. I certify that the information provided is complete and accurate, and that the source documentation will be provided upon request.
Signature
Clear
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: