• Northern Berkshire CDBG-CV Regional Microenterprise Assistance Program

    Massachusetts Community Development Block Grant Program
  • Berkshire Regional Planning Commission
    1 Fenn Street, Suite 201
    Pittsfield, MA  01201
    413.442.1521 x17
     
    This Income Certification Form  is for businesses located in Adams, Cheshire, Clarksburg, Dalton, Florida, Hancock, Hinsdale, Lanesborough, New Ashford, Peru, Savoy, Williamstown, or Windsor, MA.

  • Section I

    Business Information

  • Section II

    Required Business Documentation

  • All applicants must provide the following documentation. Please upload the appropriate files below.

    Please Note: Businesses are required to have been in operation before January 1, 2019. All US, state and local taxes must be current.

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of

  • Section III

    Family Income Summary

  • Please complete the following, providing information on the business owner as well as on all permanent residents of the business owner's family, including children. Co-owners with greater than 20% ownership may be required to submit separate documentation.

    Demographic information is confidential and collected for reporting requirements only. The Microenterprise COVID Recovery Program does business in accordance with the Federal Fair Housing Law and Federal Equal Credit Opportunity Act, and does not discriminate against any person because of race, color, age, religion, sex, marital status, or national origin.

  • Section IV

    Required Family Income Documentation

  • Please Note: A Low-to-Moderate Income (LMI) person is a member of an LMI family. Family includes, but is not limited to, the following, regardless of actual or perceived sexual orientation, gender identity, or marital status:

    1. A single person who may reside with an elderly person, displaced person, disabled person, near-elderly person, or any other single person; or

    2. A group of person residing together, and such group includes, but is not limited to: 

    (i) A family with or without children (a child who is temporarily away from the home because of placement in foster care is considered to be a member of the family)
    (ii) An elderly family;
    (iii) A near-elderly family;
    (iv) A disabled family;
    (v) A displaced family; and
    (vi) The remaining member of a tenant family.

    Instructions: This section must be completed for all members of the family living in the household who are 18+ years old. Indicate all that apply by choosing Yes or No and uploading the corresponding documents.

    Do you or your family members (those 18+ years old) have the following types of income?

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of

  • Section V

    Certification/Authorizations/Signatures

  • I/we certify that all information provided as part of this application is true and correct to the best of my/our knowledge. I/we give my/our consent to the sponsoring organization considering this application to use the information proviced herein for the purpose of grant award consideration.

  • Clear
  • Clear
  • Should be Empty: