CDBG - Section 3 Worker/Employer-Certification

1

This form, or similar, may be used by Grantees, Contractors, and Subcontractors to certify Section 3 and Targeted Section 3 status of current and/or new workers.

Section 1 is to be completed by the Section 3 Worker.
Section 2 is to be completed by the business to certify Targeted Section 3 status.

2

Name:

3

Permanent Address:

4

I am a resident of:

5

Community:

6

County:

7

Please read the following statements and check all that apply to you currently or during the time period beginning November 30, 2020.

My individual annual income was at or below 80% Area Median Income (AMI) figure for a household of 1 for the county or area in which I live. (Table at the end of this form provides annual 80% limits for each county.)

I am or was a YouthBuild participant (within a 5-year window beginning on or after November 30, 2020).

8

Start (MM/DD/YYYY):

Date

9

End (MM/DD/YYYY):

Date

10

I am or was a resident of public housing (within a 5-year window beginning on or after November 30, 2020).

11

Start (MM/DD/YYYY):

Date

12

End (MM/DD/YYYY):

Date

13

I am or was a resident of other public housing projects or Section 8-assisted housing (within a 5-year window beginning on or after November 30, 2020).

14

Start (MM/DD/YYYY):

Date

15

End (MM/DD/YYYY):

Date

16

None of the above apply to me.

17

I affirm that the above statements are true, complete, and correct to the best of my knowledge and belief. Any false statements made knowingly and willfully may subject the signer to penalties under Section 1010 of Title 18 of the United States Code.

18

Printed or Typed Name

19

Signature

20

Date

21

Version 11/22/2022

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Employer Name:

23

Please read the following statements and check all that apply to your employee currently or during the 5-year window prior to the date of certification. The 5-year period cannot begin before November 30, 2020.

The employee listed on page one of this form is employed by our company, which is a Section 3 Business concern.

(For Housing and Community Development projects) Lives within the project service area as defined by the Grantee. (Employers should obtain a map of the project service area from the Grantee.) Typically, this is a 1-mile radius of the project site or is within the allowed project service area (within the 5-year window). If fewer than 5,000 people live within one mile of the project site, the area is extended to a circle centered on the project site that encompasses a population of 5,000 people according to the recent census.

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Dates of Residence:

25

None of the above apply.

26

I affirm that the above statements are true, complete, and correct to the best of my knowledge and belief. Any false statements made knowingly and willfully may subject the signer to penalties under Section 1010 of Title 18 of the United States Code.

27

Printed or Typed Name and Title

28

Signature

29

Date

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2022 CDBG Income Limits by County

County	80% Area Median Income (AMI) for a Household of 1
Alameda County	74,200
Alpine County	50,900
Amador County	48,550
Butte County	43,650
Calaveras County	50,400
Colusa County	43,650
Contra Costa County	74,200
Del Norte County	43,650
El Dorado County	56,750
Fresno County	43,650
Glenn County	43,650
Humboldt County	43,650
Imperial County	43,650
Inyo County	46,350
Kern County	43,650
Kings County	43,650
Lake County	43,650
Lassen County	45,000
Los Angeles County	66,750
Madera County	43,650
Marin County	104,400
Mariposa County	43,650
Mendocino County	45,000
Merced County	43,650
Modoc County	43,650
Mono County	45,000
Monterey County	63,700
Napa County	70,550
Nevada County	55,100
Orange County	75,900
Placer County	56,750

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CDBG - Section 3 Worker/Employer-Certification

County	80% Area Median Income (AMI) for a Household of 1
Plumas County	45,750
Riverside County	49,300
Sacramento County	56,750
San Benito County	58,900
San Bernardino County	49,300
San Diego County	72,900
San Francisco County	104,400
San Joaquin County	46,350
San Luis Obispo County	61,250
San Mateo County	104,400
Santa Barbara County	78,350
Santa Clara County	92,250
Santa Cruz County	87,350
Shasta County	44,450
Sierra County	50,400
Siskiyou County	43,650
Solano County	60,800
Sonoma County	66,550
Stanislaus County	44,650
Sutter County	43,650
Tehama County	43,650
Trinity County	43,650
Tulare County	43,650
Tuolumne County	46,600
Ventura County	70,250
Yolo County	55,550
Yuba County	43,650

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Section 3 Forms