ATLANTIC CITY CDBG PROGRAM

ATLANTIC CITY CDBG PROGRAM

Beneficiary Self-Certification Form (2025 Income Limits)
This program has recieved assistance from Atlantic City through funds that were provided in part by the U.S. Department of Housing and Urban Development (HUD) which requires that the following information be completed. This information will be kept confidential.
Name

Last NameFirst Name
Address

Street Address

Apt #

CityState / Province

Postal / Zip Code
Address

Street Address

CityState / Province

Zip Code
Address

Street Address

CityState

Zip Code
Family Size
Source(s) of Income:
In the chart below, find your family size, then circle the income level for your family's current annual income. Total family income includes income from all sources (wages, unemployment, social security, public assistance, interest and dividends, worker's comp, etc.) for all members of your family whoa are at least 18 years of age. A family is defined as all personss living in the same household who are related by birth, marriage, or adoption.
My Family income is higher than the amounts listed above for my family size
Amount for 1 Person under Extremely Low Income Limits
Race (must check one):

WhiteBlack/African-AmericanAsianAmerican-Indian/Alaskan NativeNat. Hawaiian/Other Pacific IslanderOther Multi-Racial
Ethnicity (must check one)

HispanicNon-Hispanic
I attest that the information provided is true and correct to my knowledge. I understand that the information listed on this form may be subjuct to verfication by Atlantic City and/or by the U.S. Department of Housing and Urban Development (HUD), the Office of the Inspector General, or their authorized respresentatives.
Beneficiary Signature
WARNING: Title 18, Section 1001 of the U.S. Code states that a person knowingly and willingly making false or fraudulent statements to any department of the United States Government.
For more information call (609)347-5330
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