2024 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. All individuals 18 years of age and older are considered as contributors to annual household income unless they are a full-time student. Both parents/guardians are required to sign off on this form and anyone else 18 & older that meets the description above.
1st Parent/Guardian Signature
*
2nd Parent/Guardian Signature
*
Additional Household Contributor Signature
*
Date
*
-
Month
-
Day
Year
Date
Please provide proof of income to maggie@wigs4kids.org once you complete this form to help us comply with federal regulations. Thank you for your support!
Submit
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