Beneficiary Self-Certification Form

Program Name

Program Dates

This program has received 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

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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 who are at least 18 years of age. A family is defined as all persons 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. (Check the box only if it applies)

Yes

If, Yes, my family income is:

Race

White

Black/African American

Asian

American Indian/Alaskan Native

Nat. Hawaiian/Other Pacific Islander

Other Multi-Racial

Ethnicity

Hispanic

Non-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 subject to verification 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 representatives.

Beneficiary Signature

Date

Beneficiary Self-Certification Form

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Advisory Board:

Board of Directors: